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I 


WAR    SURGERY 


WAR     SURGERY 


BY 

EDMOND  DELORME 

M^DECIN    INSPECTEUR   G^N^RAL    DE    l'aRMEE 

ANCIEN    PRESIDENT    UU    COMITE    CONSULTATIF    DE    SANT6    DE    l'aRm6e 

MEMBRE    DE    l'aCAD^MIE    DE   M^DECINE 

MEMBRE    ET   ANCIEN    PRESIDENT    DE    LA    SOCI6t6    DE    CHIRURGIE 


TRANSLATED    BY 

H.    DE    MERIC 

SURGEON    TO    IN-PATIENTS,    FRENCH    HOSPITAL,    LONDON 


WITH  ILLUSTRATIONS 


PAUL  B.  HOEBER 

67  &  69  EAST   59TH   STREET 
NEW   YORK 
1915 


{Printed  in  England]^ 

HI  \^> 


EXTRACTS  FROM  AUTHOR'S  PREFACE 

^  ;f:  ;{i  ^  5(c 

Unity  of  doctrine  is  absolutely  essential.  This  I  set  forth 
in  my  "  Advice  to  Surgeons."  In  order  to  avoid  the  excess 
of  operative  measures  which  has  been  seen  in  recent  wars, 
it  was  urgent  to  lay  stress  on  the  almost  uniform  conserva- 
tism of  our  present  surgery,  but  a  rapid,  synthetic  outline 
was  not  sufficient.  It  was  necessary  to  complete  it  by 
information  on  the  special  aspect  of  the  wounds  we  see,  on 
their  complications,  and  also  by  adequate  details  with  regard 
to  the  best  methods  for  us  to  follow.  Therefore  the  present 
work  became  a  necessary  supplement. 

It  is  intended  both  for  beginners  and  also  for  those  sur- 
geons whose  everyday  practice— often  specialized — has  not 
allowed  them  to  follow  the  advances  made  in  military  surgery. 
I  have  been  obliged  to  give  a  scientific  form  to  many  descrip- 
tions, and  to  lay  stress  on  legitimate  reasons  for  the  methods 
I  have  advised ;  I  was  also  forced  to  give  up  the  concrete, 
imperative  form,  which  is  excellent  in  addressing  young 
surgeons  just  entering  the  profession,  but  insufficient  to 
secure  conviction  from  those  on  whom,  in  the  rear,  the  whole 


vi      EXTRACTS  FROM  AUTHOR'S  PREFACE 

weight  of  the   most  important  treatment  of  the  wounded 
will  fall. 

I  hope  'both  these  categories  will  follow  my  writings  in 

the    few   moments    of    leisure    left   them    by   their   daily 

work.  .  .  .     They  will  be  able  to  turn  to  account  what  the 

book  teaches  them,  and  our  brave  wounded  will  be  benefited. 

***** 


TRANSLATOR'S  NOTE 

In  translating  the  work  of  so  distinguished  a  military 
surgeon  as  Dr.  Delorme,  I  have  endeavoured  so  far  as 
possible  to  keep  closely  to  the  French  text. 

H.  DE  MERIC. 


CONTENTS 


CHAPTER 


I.    WEAPONS    AND    PROJECTILES    (rIFLES)  -  -  I 

II.    PROJECTILES    (guns)             -                  -  -  -  l6 

III.  WOUNDS    OF    DIFFERENT   TISSUES  -  -  23 

IV.  WOUNDS    OF    ARTERIES        -                  -  -  "  3^ 
V.    WOUNDS    OF    THE    NERVES                   -  -  -  54 

VI.    FOREIGN    BODIES    -                 -                 -  -  -  61 

VII.    BONY    LESIONS    OF    THE    DIAPHYSES  -  1^ 
VIII.    LESIONS    OF    THE    ARTICULATIONS  -  -  lO;^ 
IX.    GENERAL    COMPLICATIONS     OF    WOUNDS  BY    FIRE- 
ARMS -                  -                  -                 -  -  -  113 

X.    WOUNDS      BY      LARGE      PROJECTILES     AND     THEIR 

FRAGMENTS     -                  -                  -  -  "  I23 

XI.    AMPUTATION  -  -  -  -  -I26 

XII.    WOUNDS    OF   THE    SKULL   AND    BRAIN  -  -  1 28 

XIII.  WOUNDS    OF    THE    FACE       -                  -  -  -  145 

XIV.  WOUNDS    OF    THE    NECK      -                 -  -  "152 
XV.    WOUNDS    OF    THE    CHEST    -                 -  -  "  158 

XVI.    WOUNDS    OF   THE    ABDOMEN               -  -  -  167 

vii 


viii  CONTENTS 

CHAHTEK  PAGE 

XVII.    WOUNDS    OF    THE     LUMBAR    REGION    AND    OF   THE 

KIDNEYS  -----  i8l 

XVIII.    WOUNDS    IN    THE    REGION    OF    THE    PELVIS  -  184 

XIX.    WOUNDS    OF     THE    VERTEBRAL     COLUMN     AND     OF 

THE    SPINAL    CORD  -  -  -  -  I90 

XX.    WOUNDS    OF    THE    UPPER    LIMBS      -  -  -  I97 

XXI.    WOUNDS    OF    THE    LOWER    LIMBS      -  -  -  21 7 


INDEX 


243 


WAR    SURGERY 

CHAPTER    I 

WEAPONS 

The  weapons  used  in  warfare  are  either  defensive 
(helmets,  cuirass)  or  offensive  (cold  steel,  firearms).  We 
will  not  stop  to  consider  defensive  ones,  as  projectiles  from 
modern  rifles  go  through  them  at  whatever  distance  an 
action  is  engaged. 

Cold  Steel. 

Amongst  cold  steel  weapons  we  may  include  the  bayonet, 
the  sword-bayonet,  the  sabre-bayonet,  the  cavalry  sword, 
the  lance. 

Bayonets  have  a  straight  styloid  blade  with  a  slender 
point,  two  sides  (Lebel  rifle),  and  sharp  serrated  edges. 
Some  are  merely  a  kind  of  hunting-knife  (Germany,  Austria, 
England,  Italy). 

Bayonets  are  employed  as  puncturing  or  stabbing  weapons, 
the  direction  being  specially  towards  the  abdomen  or  the 
upper  part  of  the  lower  limbs.  The  serious  injuries  thus 
inflicted  are  somewhat  analogous  to  wounds  made  by 
pointed  instruments,  or  by  those  that  at  the  same  time  are 
pointed  and  cutting. 

During  the  Balkan  War  bayonet  injuries  were  very 
frequently  observed.  In  certain  battles  they  reached  a  pro- 
portion of  lo  per  cent,  of  the  wounded.    The  injured  regions 


2  WEAPONS 

were  mainly  the  body,  the  abdomen,  the  upper  part  of  the 
lower  limbs. 

The  sabre  or  sword,  having  a  blade  with  hollow  sides, 
straight  or  curved,  is  used  for  stabbing  and  thrusting  in  the 
same  way  as  the  bayonet,  or  as  a  cutting  weapon.  The 
wounds  it  inflicts  are  generally  numerous  (two,  four,  twenty). 
They  are  usually  found  on  the  head,  the  right  elbow,  the 
upper  part  of  the  left  arm. 

The  lance  is  a  pointed  weapon  that  has  considerable 
power  behind  it.  The  head  of  the  French  lance  is  15  centi- 
metres long  (5-9  inches)  and  2  centimetres  (07  inch)  in 
diameter  ;  its  section  is  quadrangular.  The  head  of  the 
German  lance  is  30  centimetres  long  (11 -8  inches)  and 
15  millimetres  (o-6  inch)  in  diameter  ;  its  section  is  tri- 
angular. In  the  attack  the  point  of  the  lance  is  directed 
against  the  trunk. 

Wounds  by  cold  steel,  rarely  observed  during  relatively 
recent  wars,  now  tend  to  increase  in  number.  During  the 
war  of  1870  only  600  cases  were  recorded  among  98,000 
wounded.  They  now  occur  in  the  proportion  of  5  per 
cent. 

Weapons  of  Offence  (Firearms). 

These  comprise  rifles,  mitrailleuses,  guns.  The  pro- 
jectiles from  these  arms  are  alone  of  interest  to  the  military 
surgeon. 

Projectiles  of  Firearms  carried  by  the  Soldier. 

They  are  projected  by  means  of  smokeless  powder,  which 
has  increased  their  velocity.  At  the  present  time  they  are 
pointed  instead  of  conical  cylinders.  Their  calibre  has  been 
reduced  from  11  to  8,  and  even  to  6-5  millimetres  (from 
0-43  to  0-31,  and  even  0-25  inch)  (D  bullet).  Their  length, 
on  the  contrary,  has  increased  :  from  2  calibres  it  has  risen 
to  3,  4,  and  even  5  (D  buUet).     Their  weight,  on  the  other 


PROJECTILES  OF  FIREARMS 


hand,  Las  diminished  :  from  25  grammes  (386  grains)  to 
15  grammes  (231  grains),  to  12-50  grammes  (193  grains) 
(bullet  D),  to  10  grammes  (154  grains)  (bullet  S). 

Some  bullets  are   of  a   uniform  composition  of  soft   or 


French  Bullets. 


Gekman  Bullets. 


S  Bullet  and  its  Section. 


AusTRL-^N  Bullets. 


Mannlicher  Bullet 
and  its  Section. 


Mauser  Bullet. 


Russian 
Bullet. 


D  Bullet. 


English 
Bullet. 


M  Bullet, 
or  Lebel 

Rifle 
Bullet. 

Belgian 
Bullet. 


Fig.   I. 


hardened  lead,  steel,  or  copper  ;  others  have  a  protective 
envelope.  The  central  nucleus  of  hardened  lead  is  covered 
by  a  casing  of  steel,  copper,  nickel,  or  nickel  silver,  which 
is  either  closed  or  open  at  the  base.  We  shall  only  describe 
the  smaller  projectiles  used  by  the  belligerent  Powers. 


4  WEAPONS 

The  German  S  Bullet. — The  S  bullet  of  the  German 
Mauser  is  a  pointed  cylinder,  ogival-shaped  projectile  of 
hardened  lead,  surrounded  by  an  envelope  of  soft  steel  plated 
with  nickel.  Its  cylindrical  part  hardly  exceeds  a  fourth  of 
its  total  length;  its  point,  which  measures  19  millimetres 
(075  inch),  is  very  tapering,  and  ends  in  a  very  small  flat 
apex,  measuring  about  i  millimetre  (0*04  inch).  Its  calibre 
is  7  millimetres  (0*28  inch),  its  length  28  millimetres  (i-io 
inches),  its  weight  10  grammes  (154  grains).  The  S  bullet 
is  shorter  and  lighter  than  the  D  bullet. 

The  Austrian  Bullet,  of  the  Austrian  Mannlicher  rifle, 
is  formed  of  hardened  lead  compressed  in  a  steel  wrapper. 
It  weighs  15-8  grammes  (244  grains) ;  it  is  31-8  millimetres 
long  (i"25  inch),  and  yg  millimetres  (o'3i  inch)  in  diameter. 
It  is  conico-cylindrical,  with  a  truncated  extremity,  which 
is  rounded  and  not  tapering. 

The  French  Bullet- — The  D  bullet  is  of  brass,  without 
envelope  ;  it  is  biogival,  the  point  being  very  sharp  in  front, 
and  the  bullet  truncated  at  its  base.  Its  calibre  is  8  milli- 
metres (0*31  inch),  its  length  39  millimetres  (1*53  inches), 
its  weight  12*80  grammes  (197  grains). 

The  M  bullet  consists  of  a  nucleus  of  hardened  lead 
surrounded  by  an  envelope  of  brass  and  steel.  Its  calibre 
is  8  millimetres  (0*31  inch),  its  length  30  millimetres 
(i-i8  inches),  its  weight  15  grammes  (231  grains). 

The  Russian  Bullet  is  ogival  in  shape,  with  a  blunt 
extremity.  It  has  an  envelope  of  nickel,  surrounding  a 
nucleus  of  hardened  lead.  Calibre,  7-6  millimetres  (0-3 
inch)  ;  length,  30*5  millimetres  (1-2  inches)  ;  weight,  1370 
grammes  (211  grains). 

The  English  Bullet  is  ogival,  with  a  blunt  apex  and 
a  casing  of  nickel.  Calibre,  770  millimetres  (0-3  inch)  ; 
length,  31  millimetres  (1-2  inches)  ;  weight,  15*90  grammes 
(215  grains). 

The  Belgian  Bullet. — Ogival,  with  blunt  apex,  nucleus 


BALLISTIC  DATA  5 

of  hardened  lead,  envelope  of  nickel.  Calibre,  7-6  milli- 
metres (0-3  inch);  length,  30  millimetres  (i*i8  inches); 
weight,  14*10  grammes  (213  grains). 

The  Mitrailleuse  fires  rifle  bullets.  Use  is  made  of  the 
infantry  rifle  cartridge.  The  multiplicity  of  the  injuries 
inflicted,  rather  than  their  nature,  distinguishes  the 
mitrailleuse. 

Ballistic  Data  (Bullets). 

The  military  surgeon  must  be  familiar  with  a  certain 
number  of  ballistic  data  in  order  to  understand,  from  a 
scientific  and  practical  point  of  view,  the  effects  of  bullets. 
We  shall  content  ourselves  by  recalling,  and  we  hope  with- 
out dryness,  the  essential  data  ;  but  it  is  quite  indispensable 
for  him  to  thoroughly  know  what  we  are  now  going  to  set 
forth. 

Velocity  Transit. — A  bullet  has  two  kinds  of  velocity : 
a  velocity  of  transit,  by  which  the  bullet  passes  through 
space  ;  and  a  velocity  of  rotation,  which  sustains  it  during  its 
trajectory. 

The  velocity  of  transit  of  a  bullet  is  one  of  the  principal 
factors  of  its  active  force  {vis  viva),  or,  in  other  words,  of  its 
power  and  of  its  eff"ects. 

The  initial  velocity  of  a  bullet  is  expressed  by  the  number 
of  metres  over  which  it  would  travel  during  the  first  second 
after  leaving  the  muzzle,  were  it  not  subjected  to  gravity. 

The  remaining  velocity,  which  is  of  far  greater  importance 
for  us  to  know,  is  the  velocity  the  bullet  still  has  at  the 
different  distances  of  its  trajectory.  The  "  remaining " 
velocity  decreases  with  the  distance  of  the  bullet  from  the 
muzzle  of  the  rifle,  owing  to  the  force  of  gravity  and  the 
resistance  of  the  air. 

The  initial  velocity  of  the  bullets  now  in  use  is  consider- 
able. The  German  bullet  S  has  the  greatest  initial  velocity, 
amounting  to  860  metres,  or  940*5  yards,  which  is  160  metres 


6  WEAPONS 

(165-0  yards)  superior  to  that  of  the  French  bullet  D;  but 
he  latter,  being  heavier,  retains  its  velocity  better  during 
the  remainder  of  its  course ;  it  is  thus  still  very  dangerous 
at  distances  at  which  the  S  bullet  is  harmless. 

The  French  bullet  D  possesses  an  initial  velocity  of 
701  metres  (767  yards);  the  M,  or  the  bullet  of  the  Lebel 
rifle,  651  metres  (712  yards);  the  Russian,  643  metres 
(703  yards) ;  the  Austrian,  626  metres  (684  yards) ;  the 
English,  574  metres  (628  yards,  etc.).* 

The  remaining  velocity  is  inversely  proportional  to  the  square 
of  the  diameter  of  the  bullet  and  proportional  to  its  leitgth  and  its 
weight. 

At  400  metres  (437*4  yards)  bullet  S  has  650  metres 
(710*8  yards)  remaining  velocity;  bullet  D  has  536  metres 
(580-2  yards). 

At  600  metres  (656'2  yards)  bullet  S  has  470  metres 
(514-0  yards)  remaining  velocity ;  bullet  D  has  470  metres 
(514-0  yards). 

At  1,000  metres  ( 1093*6  yards)  bullet  S  has  301  metres 
(329-2  yards)  remaining  velocity ;  bullet  D  has  365  metres 
(399-2  yards). 

At  2,000  metres  (2187-2  yards)  bullet  S  has  166  metres 
(i8i*5  yards)  remaining  velocity;  bullet  D  has  210  metres 
(229*7  yards). 

Velocity  of  Rotation.  —  To  maintain  the  bullet  on  its 
trajectory,  the  grooves  of  the  rifle  impart  to  it  a  rotatory 
movement.  The  longer  the  projectile,  the  greater  its  move- 
ment of  rotation  ;  the  latter,  however,  has  but  little  influence 
upon  the  effect  of  the  projectile ;  it  remains  constant  for 
the  same  projectile. 

Bascule  Movements. — The  S  and  D  bullets  are  subject 
to  movements  of  oscillation  and  of  deflection,  to  which  other 
projectiles  are  also  subject,  but  in  a  slighter  degree. 
Bullets  may  turn  cross-wise  or  with  their  base  in  front ; 

*  The  English  bullet  has  a  muzzle  velocity  of  2,000  feet-=666'6  yards. 


BALLISTIC  DATA 


7 


this  rnay  occur  when  they  encounter  a  small  obstacle  in 
their  course,  or  when  they  strike  the  human  body.  With 
bullet  M,  and  also  with  the  old  German  bullet,  at  400  metres 
a  fourth  of  such  deflection  has  been  noticed ;  at  600  metres 
one-third.  These  overturnings  occur  more  frequently  with 
the  bullets  S  and  D,  a  fact  that  the  military  surgeon  must 
bear  in  mind,  as  well  as  the  frequency  of  ricochets. 

Trajectory.  —  The  course  followed  by  the  bullet,  its 
trajectory,  was  formerly  represented  by  a  long  curve;  the 
trajectory  of  modern  bullets  is  straighter,  and  so  increases 
the  vulnerability  of  the  object  fired  at,  and  also  the  extent 
of  the  dangerous  space.  The  effect  of  the  tension  imparted 
to  the  bullet  insures  a  more  direct  trajectory.  Up  to 
500  metres  the  trajectory  of  modern  bullets  is  almost  a  straight 
line. 

Range. — The  great  speed  of  the  bullets  now  in  use 
enables  them  to  attain  a  range  of  3  kilometres,  or  more 
(3,800  metres — 2-36  miles)  in  the  case  of  bullet  D. 

Active  Power  {Vis  Viva).  —  The  damaging  effects  of 
bullets  are  dependent  on  their  active  power  {vis  viva).     This 

WV2 

is  expressed  by  the  formula  P  =  ,  W  being  the  weight 

and  V  the  velocity  of  the  projectile. 

The  following  table  represents  in  kilogrammetres  the 
initial  active  power  {vis  viva)  and  the  remaining  velocity  of 
the  S  bullet,  of  the  Mannlicher,  and  of  the  French  D  bullet : 


Distances  in  Metres. 

0 

100 

200 

300 

400 

500 

600 

700 

800 

900 

1,000 

2,000 

Germany 
Austria   ... 
France   . . . 

310 
344 

239 

223 

230 

186 
167 
183 

145 
139 
147 

113 
119 
121 

90 
104 
lOI 

76 
92 
86 

68 
81 
73 

63 

73 
64 

58 
67 

56 

53 
61 

50 

23 
31 
19 

This  table  shows  that  the  acting  or  damaging  power 
is  practically  the  same  for  the  three  projectiles ;  it  is 
tremendous  at  100  metres,  considerable  up  to  500  metres. 


8  WEAPONS 

From  500  to  1,000  metres  the  damaging  power  decreases 
rapidly  ;  it  is  very  small  between  1,000  and  2,000  metres. 

We  thus  understand  why  the  classical  works  on  army 
surgery,  when  dealing  with  the  effects  of  bullets,  are  always 
careful  to  bring  these  effects  within  touch  of  the  question 
of  the  distance  at  which  the  firing  has  taken  place,  and  to 
speak  of  very  short  distances  from  o  to  100  metres,  short 
distances  up  to  500  metres,  middle  distances  from  500  to 
800  and  1,000  metres,  great  distances  from  1,000  metres 
upwards.  The  greater  the  active  power  (vis  viva),  the  more 
extensive  are  the  injuries  inflicted. 

The  power  of  penetration  of  a  bullet  is  dependent  on  its 
active  power  (vis  viva),  on  the  extent  of  the  surface  on 
which  it  strikes,  on  its  density  of  section — i.e.,  the  weight 
that  prolongs  backwards  each  unit  of  surface  that  is  oppos- 
ing resistance.  This  is  the  reserve  of  active  molecules. 
A  last  condition  that  influences  the  penetrating  force  is  the 
state  of  its  surface  of  peripheral  friction. 

It  follows  from  the  above  that  the  pointed  S  and  D  bullets 
have  more  power  of  penetration  than  the  cylindro-ogival 
bullet  with  a  flat  apex ;  that  the  D  bullet,  being  longer,  has 
more  power  of  penetration  than  the  shorter  S  bullet ;  that 
a  projectile  that  has  ricochetted  and  struck  sideways  is  less 
penetrating  than  one  fired  point-blank.  The  resistance 
opposed  by  the  tissues  to  penetration,  of  projectiles  of  equal 
speed,  is  inversely  proportional  to  the  square  of  the  diameters. 

The  bullet  exercises  on  any  obstacle  it  meets  a  more  or 
less  great  pressure.  The  coefficient  of  pressure  depends  on  the 
active  power  [vis  viva)  and  on  the  calibre  of  the  projectile. 
The  smaller  the  calibre,  the  greater  the  pressure. 

Ricochets. — Injuries  inflicted  by  ricochetting  bullets  are 
very  frequent.  They  are  observed  in  the  proportion  of  1  in  3 
of  all  cases. 

A  projectile  ricochetting  from  the  ground  is  deflected, 
and  strikes  the  body  obliquely  or  transversely.     It  is  put 


MODUS  OPERANDI  OF  BULLETS  9 

out  of  shape,  flattened,  turned  out  of  its  course,  broken  up, 
separated  from  its  envelope,  and  so  the  number  of  injuries 
to  which  it  gives  rise  is  multiplied.  To  be  put  out  of  shape 
a  leaden  projectile  must  have  a  velocity  of  450  metres,  a 
bullet  with  an  envelope  a  remaining  velocity  of  750  metres 
(Journee). 

The  S  bullet,  formed  of  hardened  lead  and  covered  by 
its  envelope,  is  more  easily  put  out  of  shape,  flattened,  and 
broken  up  on  striking  the  ground,  than  the  D  bullet,  which 
is  made  of  brass. 

Injuries  inflicted  by  vicochetting  projectiles  are  more  serious 
than  those  caused  by  bullets  fired  point-blank. 

Modus  Operandi  of  Bullets. 

Pointed  bullets  such  as  the  S  and  D  bullets  make  a 
puncture-like  opening  in  the  tissues  when  they  reach  them 
from  a  point-blank  discharge.  After  penetrating,  they  push  the 
tissues  aside,  but  without  greatly  bruising  them,  thus  creating 
very  favourable  conditions  for  spontaneous  healing.  More- 
over, they  do  not  carry  with  them  to  any  great  extent  foreign 
bodies  derived  from  the  clothes  of  the  ivounded  man.  These  are 
essential  points  to  bear  in  mind. 

When  the  S  and  D  bullets  have  tipped  over — when  they 
have  ricochetted  in  their  course — they  strike  the  body  with 
a  much  enlarged  irregular  surface,  and  so  exert  sixong  pressure 
upon  the  tissues.  Their  mechanism  then  becomes  punch-like, 
with  a  tearing  and  bruising  action.  Moreover,  they  carry 
with  them  foreign  bodies  derived  from  the  clothes,  and  may  be 
soiled  by  contact  with  the  earth.  These  are  points  of  paramount 
importance. 

The  greater  the  remaining  velocity  of  the  bullet  and  the 
more  tearing  its  efl"ects  (bullets  that  have  tipped  or  lost 
their  shape),  the  greater  the  amount  of  active  force  it 
imparts  to  particles  of  tissue  it  separates.  The  fragments 
of  tissue  torn  off  play  the  part  of  secondary  projectiles,  which, 


lo        .  WEAPONS 

at  first  propelled  in  front  of  the  bullet,  whose  track  they 
prepare  by  slipping  over  its  sides,  transversely  enlarge  the 
track  of  the  wound,  giving  rise  to  more  or  less  bruising  and 
disturbance. 

The  intensity  of  the  action  of  the  so-called  secondary 
projectiles  varies  with  the  velocity  of  the  bullet,  its  shape, 
the  nature  of  the  tissues  with  which  it  has  come  into  contact, 
and  with  the  easy  dissociation  of  these  last,  and  their  mobility. 

An  intense  action  is  chiefly  observed  with  projectiles  pos- 
sessing very  great  or  great  velocities — that  is  to  say,  at  short 
distances,  varying  from  o  to  loo  up  to  500  metres  {from 
o  to  109  and  to  ^^y  yards  (zone  of  so-called  explosive  effects). 

With  pointed  projectiles,  discharged  at  point-blank  range, 
it  is  possible  that  the  above-mentioned  effects  may  no 
longer  be  seen.  At  all  events,  they  occur  more  rarely  than 
W'ith  conico-cylindrical  bullets  having  a  flat  apex,  or  with 
bullets  having  a  calibre  of  more  than  8  millimetres  (o'3i 
inch,  Gras  bullets).  On  the  other  hand,  they  are  produced 
by  the  S  and  D  bullets  when  these  projectiles  become 
deviated  whilst  proceeding  at  a  high  velocity.  This  has 
been  observed  over  and  over  again  in  the  present  war. 

Intense  divulsive  and  propulsive  action  is  exercised 
with  greater  facility  the  more  the  tissues  are  capable  of 
dissociation,  the  less  they  show  elasticity  (muscles),  and  the 
freer  the  molecules  (parenchymatous  organs,  brain).  In- 
compressibility  and  their  frequent  projection  explain  the 
awful  extension  of  the  havoc  that  at  times  is  wrought 
by  bullets  upon  organic  receptacles  (bladder,  intestines, 
stomach,  gall-bladder).  Not  only  may  these  receptacles 
present  enormously  enlarged  apertures  of  exit,  but  they 
may  also  burst,  and  show  large  openings  at  some  distance 
from  the  track  pursued  by  the  bullet. 

The  most  elastic  tissues  of  the  body  (tendons,  fasciae, 
aponeurosis),  especially  when  they  are  movable  (tendons 
of  the  wrist,  of  the  instep),  can  transmit  for  some  distance 


MODUS  OPERANDI  OF  BULLETS  n 

the'  active  force  {vis  viva)  imparted  by  a  bullet.  Thus  they 
bruise  and  split  up  the  neighbouring  and  less  resistant 
tissues  (integuments,  muscles).  Fragments  of  bone  de- 
tached by  a  bullet  act  like  fragments  of  the  projectile  or 
like  the  bullet  itself,  forming  a  shower  of  secondary  pro- 
jectiles, which,  from  the  centre  of  the  injured  limb,  are 
propelled  outwards  through  the  soft  tissues. 

When  the  active  powev  (vis  viva)  is  of  average  strength  (beyond 
the  500  metres,  and  up  to  the  1,000  metres  range),  the  action 
of  the  bullet  remains  localized.  The  injury  is  of  the  nature  of  a 
puncture  or  an  abrasion,  with  a  weak  projection,  and  more 
rarely  with  hard  or  soft  secondary  projectiles.  Such  is  the 
usual  normal  type  of  the  lesions. 

When  the  active  power  [vis  viva)  is  weak  (beyond  the 
range  of  1,000  metres),  the  lesions  are  still  more  circum- 
scribed ;  again,  the  bullet  acts  by  puncture,  and  especially 
separates  the  fibres  of  the  tissues. 

The  zones  of  the  action  of  a  bullet  have  been  classed  as 
follows  : 

1.  Explosive  zones  (up  to  500  metres). 

2.  Perforation   zones  (regular  course,   from    500   to    2,000 

metres). 

3.  Contusion  zones  (beyond  2,000  metres). 

Although  the  above  classification  has  been  criticized,  it 
deserves  to  be  maintained  for  bullets  such  as  those  of  the 
Lebel  rifle. 

Projectiles  of  a  calibre  greater  than  8  millimetres 
(0-31  inch),  in  addition  to  their  divulsive  effect,  have  a 
vibratory  action  which  may  be  transmitted  over  a  more  or 
less  considerable  distance  from  the  bullet's  course,  this 
vibratory  action  showing  itself  by  phenomena  of  inhibition 
and  of  local  or  general  shock.  With  pointed  bullets  fired 
point-blank,  these  phenomena  are  no  longer  observed.  It 
may  even  happen  that  the  wounded,  even  when  their  atten- 


12  WEAPONS 

tion  has  not  been  taken  off  by  the  excitement  of  the  battle, 
are  unaware  of  the  very  serious  injuries  inflicted  on  them. 
The  S  and  D  bullets  pass  through  the  flame  of  a  candle 
without  causing  it  to  flicker.  On  the  contrary,  when  de- 
flected, the  S  and  D  bullets  frequently  produce  this  shock. 

The  considerable  active  power  {vis  viva)  possessed  by  the 
bullets  now  in  use  enables  them  to  pass  through  several 
bodies,  and  a  fortiori  through  more  than  one  limb.  The  S 
bullet  fired  from  a  distance  of  2,000  metres  can  still  go 
through  two  men.  The  damage  extends  from  the  first  to 
the  last  body  or  limb  traversed  by  the  projectile,  if  they  are 
near  to  one  another. 

An  active  power  {vis  viva)  of  8  kilogrammetres  is  sufficient 
to  disable  the  combatant. 

Contour  wounds  no  longer  occur  with  point-blank  firing. 

The  So-called  Humanitarian  Bullets. — The  modern 
S  and  D  bullets  cause  a  considerable  immediate  mortality, 
a  fact  often  too  little  remembered  by  the  surgeon  who  treats 
the  wounded  in  the  rear.  The  fortunate  influence  exercised 
by  their  pointed  form  and  their  small  diameter  is  counter- 
balanced by  the  frequency  of  their  turning  over ;  this 
widens  the  bullet's  track  from  its  aperture  of  entry  to  its 
deep  resting-place,  and  gives  rise  to  contamination  of  the 
wound  by  the  foreign  bodies  carried  in  by  the  bullet. 

Therefore  S  and  D  projectiles  are  not  humanitarian. 

According  to  Journee,  fatal  injuries  are  in  the  ratio  of 
25  per  cent.,  serious  injuries  15  per  cent.,  slight  injuries 
60  per  cent.  Generally,  the  same  ratio  is  observable 
throughout. 

If,  in  a  certain  measure,  owing  to  their  small  calibre,  to 
their  pointed  shape,  and,  as  in  the  case  of  the  D  bullet,  to 
their  composition  in  a  single  piece,  the  present  bullets  give 
rise  to  a  long  series  of  slight  traumatisms,  whose  very  mild- 
ness, when  the  wounded  are  taken  to  the  rear,  strikes  not 
only  the  surgeons,  but  also  the  general  pubHc,  there  is  no 


MODUS  OPERANDI  OF  BULLETS  13 

reason  for  bestowing  upon  them,  and  on  some  of  those  that 
have  been  used  previously,  the  so  abusively  eulogistic  Ger- 
man appellation  of  humanitarian  bullets.  The  average  of 
wounds,  other  than  very  small  ones  of  the  soft  parts, 
remains  grave ;  therefore  we  may  repeat  in  regard  to  these 
bullets  what  we  have  said  in  speaking  of  the  others  :  it  is 
truly  pushing  the  love  for  paradox  very  far  to  call  humani- 
tarian a  bullet  that  goes  through  several  men  when  fired 
from  a  short  distance,  and  that  is  capable  of  causing  great 
slaughter  in  a  zone  of  more  than  3,000  metres. 

The  adoption  of  bullets  that,  on  meeting  the  slightest 
obstacle,  turn  on  their  axis,  strike  obliquely  or  trans- 
versely, giving  rise  to  wounds  that  are  often  relatively  of 
a  large  size,  the  making  use  of  bullets  that  so  easily  turn 
over  in  the  tissues  and  drive  forward  "  foreign "  bodies, 
certainly  does  not  constitute  progress  from  a  humanitarian 
point  of  view. 

The  greater  the  velocity  of  the  bullet,  the  more  serious 
are  the  lesions,  the  graver  the  fractures  of  bone. 

Other  things  being  equal,  the  extent  and  severity  of  the 
injuries  caused  by  rifle-fire  depend  on  the  active  power 
{vis  viva)  of  the  bullet.  But,  far  from  the  distance  between 
the  combatants  being  increased,  it  has  remained  unchanged  ; 
even  it  was  noticed  during  the  Balkan  War,  and  has  already 
been  observed  in  the  present  war,  the  distance  tends  to 
decrease,  and  firing  is  carried  on  in  zones  in  which  the 
bullets  acquire  an  excessive  active  power  {vis  viva),  and  the 
wounds  they  inflict  are  amongst  the  most  dangerous  known. 
In  short-distance  rifle-firing  the  mortality  is  appalling.  The 
kind  of  madness  soldiers  feel  in  a  charge  {furie  frangaise)  is 
heavily  paid  for,  and  charging  would  be  most  criminal  were 
it  useless. 

To  appreciate  as  a  whole  the  gravity  of  the  injuries 
inflicted  by  bullets,  we  must  take  into  account  not  only 
those  injuries  the  surgeon  sees  in  patients  brought  to  the 


14  WEAPONS 

rear,  but  also  the  wounds  that  are  treated  at  the  front, 
the  patients  being  subsequently  removed  to  hospital,  and 
the  injuries  seen  on  the  battlefield  in  soldiers  that  have 
been  killed.  When  all  these  data  are  united,  instead 
of  one  only  being  kept  in  view,  the  impression  with 
regard  to  the  small  bullets  now  in  use,  far  from  being 
favourable,  becomes,  on  the  contrary,  unfavourable. 

If  all  these  injuries  be  taken  as  a  whole,  the  pointed  bullets 
now  in  use  do  not  present  any  essential  differences  from  the 
projectiles  used  in  former  times. 

Explosive  Bullets  or  Dum-Dum  Bullets. — At  the 
outbreak  of  every  war  there  are  always  questions  raised 
with  regard  to  the  employment  of  dum-dum  bullets.  It 
is  so  to-day.  We  have  seen  wounded  men  in  the  present 
campaign  concerning  whom  this  old  error  has  been  brought 
forward.  The  terrible  injuries  that  have  given  rise  to  this 
mistake  differ  so  greatly  in  character  from  those  usually 
observed  that  it  seems  impossible  to  attribute  them  to  the 
action  of  a  bullet  which  causes  but  very  small  apertures  of 
entry  and  of  exit.  This,  however,  is  not  so.  In  such  cases 
it  is  a  question  of  explosive  shots  due  to  projectiles  of  very 
high  velocity  becoming  more  or  less  broken  up  in  their 
course  through  the  tissues.  The  fury  with  which  our 
soldiers  have  many  times  fallen  on  the  enemy,  and  the  fact 
of  their  being  hit  by  bullets  from  very  short  distances, 
sufficiently  account  for  these  wounds  that  need  no  further 
explanation. 

Systematic  use  of  explosive  bullets  would  show  a  want  of 
common  sense,  because  we  rely  on  the  effects  of  ricochetted 
bullets,  a  ricochet  occurring  in  the  proportion  of  i  in  3  of 
bullets  discharged  ;  besides,  an  explosive  bullet  can  no 
longer  hit  a  man  if  it  has  touched  the  ground,  however 
slightly. 


Fig.  2.— Effects  of  Explosive  Fire  (S  Bullet). 
{Augtist  20,  1914.) 


CHAPTER  II 

PROJECTILES   FROM    FIREARMS   NOT 
CARRIED   BY   INFANTRY  (GUNS) 

These  projectiles  are  those  of  field,  motmtain,  garrison, 
siege,  naval,  and  coast  guns.  Projectiles  from  garrison,  siege, 
naval,  and  coast  guns,  being  chiefly  directed  against 
armoured  objects  in  defence  or  attack,  are  distinguished 
from  the  first  by  their  massiveness  and  by  the  small  tendency 
they  have  to  divide.  We  will  not  stop  to  consider  them. 
On  the  other  hand,  the  two  first-mentioned  guns,  mainly 
destined  to  be  used  against  troops,  will  be  minutely  studied 
from  the  point  of  view  of  their  construction,  their  ballistic 
qualities,  and,  lastly,  of  their  effects. 

Shells  of  Field  Artillery. 

As  a  general  rule,  shells  from  field  guns  are  metallic 
cylinders  of  cast  iron  or  steel,  cylindro-conoidal  in  shape, 
with  thick  walls  ;  the  shell  is  subdivided  into  cavities  which 
contain  the  bursting  charge,  and  usually  the  projectiles. 

The  shell's  anterior  extremity,  which  is  well  strengthened, 
and  is  called  the  ogive,  contains  the  fuse,  which  is  separable, 
and  is  formed  by  an  irregular  mass  of  copper. 

The  shell's  posterior  extremity,  which  is  also  strengthened, 
and  can  often  be  separated,  is  called  the  rear-piece. 

On  the  outer  surface  of  the  shell  are  the  forcing  hands, 
which  can  be  detached ;  they  are  formed  of  copper  rings, 

i6 


SHELLS  OF  FIELD  ARTILLERY  17 

of  girdles  of  lead,  of  side-pieces,  of  nuts.  Some  howitzer 
shells  are  provided  with  discs. 

The  shell,  when  acted  upon  by  the  time  fuse,  explodes  in 
the  air  ;  when  acted  upon  by  a  percussion  fuse  it  explodes 
on  striking  the  ground.  Some  fuses  have  a  double  action, 
and  are  both  time  and  percussion  fuses. 

Shells  are  designated  according  to  their  calibre  :  shell  of 
75,  of  77,  etc.,  or  according  to  their  mode  of  bursting  : 
shells  having  a  systematic  mode  of  bursting,  shells  con- 
taining grape-shot  (mitraille),  shrapnel,  explosive  shells. 

1.  Shells  whose  Bursting  is  Systematic  are  projectiles 
with  double-lined  sides,  showing  lines  of  rupture,  and 
breaking  up  into  large  fragments ;  others  of  the  same  kind 
have  in  the  interior  of  their  thick  external  envelope  a  number 
of  piled  up  cast-iron  rings,  which  break  up  into  large  and 
sharp  fragments.     These  shells  are  but  little  employed. 

2.  Shells  containing  Mitraille  have  an  outer  shell 
containing  metallic  discs  hollowed  out  into  alveoli,  for 
round  bullets  from  12  to  15  millimetres  (0-47  to  0*59 
inch).  Segmentation,  which  takes  place  at  the  level  of  the 
alveoli,  sets  free  fragments  of  cast  iron  irregularly  cubic  in 
shape  and  with  sharp  angles.  Such  is  the  present  French 
mitraille  shell. 

3.  Shrapnel. — The  outer  shell  in  this  instance  is  thin  ; 
it  rests  in  front  upon  a  heavy  ogive,  at  the  back,  upon  a 
thick  rear-piece.  The  interior  of  the  shell  is  filled  with  free 
spherical  bullets  (10  to  16  millimetres,  0*39  to  0-63)  of 
hardened  lead.  In  some  shrapnel  the  charge  of  powder  is 
placed  behind,  by  the  rear-piece  (Austria)  ;  great  force  is 
thus  imparted  to  the  bullets.  In  other  cases  the  charge  is 
placed  in  front ;  it  then  lessens  the  speed  of  the  bullets,  but 
facilitates  their  scattering.  Lastly,  the  charge  may  be 
mixed  with  the  bullets  ;  this  facilitates  their  scattering,  and 
increases  their  power  (French  shells). 

With  this  shell  the  ignition  of  the  charge  is  secured  by  a 


PROJECTILES  FROM  FIREARMS 


central  tube.  The  French  shrapnel  of  75  centimetres  con- 
tains 290  bullets  of  12  grammes  each  (185  grains)  ;  the 
German  shrapnel  of  77  centimetres  has  300  bullets  of 
10  grammes  (154  grains)  each. 


Fig. 


-German  Shrapnel  Bullets. 
(Natural  size.) 


Fig.  4. — German  Shrapnel. 

The  shrapnel  of  the  German  field-howitzer  contains 
500  bullets  of  10  grammes  each. 

4.  Explosive  Shells.  —  Their  moderately  thick  steel 
walls  are  hollowed  out  into  a  large  cavity  filled  with  an 
explosive  material  (gun-cotton,  melinite,  cresylite,  etc.). 
The  explosive  shells  are  generally  fired  in  the  proportion  of 
I  to  3  by  all  artillery. 


SHELLS  OF  FIELD  ARTILLERY  19 

The,  variable  quantity  of  explosive  material  contained 
in  a  shell  has  a  very  great  influence  on  the  effects  pro- 
duced. The  German  shell  containing  but  150  grammes 
(2,315  grains)  of  melinite  is  far  less  destructive  than  the 
French  grape-shot  shell,  which  contains  800  grammes 
(176  pounds)  of  the  same  material.  From  the  outset  of  the 
war  considerable  difference  has  been  observed  between  the 
injuries  inflicted  by  German  and  French  shells. 

5.  Mixed  Universal  Shells  unite  the  characteristics 
of  shrapnel  and  of  explosive  shells. 

A  universal  shell  with  a  double  effect  has  been  adopted 
by  Germany  for  her  field-gun  98  and  for  her  howitzer  105. 
In  its  posterior  part  there  is  a  powder-charge  to  project 
the  bullets ;  in  the  centre  are  the  bullets  mixed  up  with  a 
charge  of  powder.  This  central  part  of  the  shell  is  crossed 
by  a  tube  which  secures  the  ignition  of  the  charge  in  the 
posterior  portion  of  the  shell.  Finally,  the  ogive  in  front 
contains  a  strong  charge  of  an  explosive.  The  shell  may 
be  used  as  shrapnel  with  time  fuse,  causing  deflagration  of 
the  charge  behind,  or  as  an  explosive  shell  with  percussion- 
fuse,  with  or  without  delay  in  the  explosion  after  the 
contact  shock,  through  detonation  of  the  charge  in  front. 
Thus  it  may  be  easily  understood  that  mixed  shells  which 
project  shrapnel  and  sharp  fragments  of  steel  in  the  same 
way  as  an  explosive  shell  may  give  rise  to  traumatisms  of  a 
special  nature  (Ferraton). 

Case-shot  are  cylinders  of  sheet-zinc  containing  round 
leaden  bullets  held  together  by  sulphur.  When  fired  at  a 
short  range,  these  cylinders  burst  at  once  and  scatter  the 
leaden  bullets ;  these  are  analogous  to  shrapnel  bullets, 
although  heavier  (40  grammes,  or  617  grains,  France). 
Great  use  was  made  of  these  projectiles  during  the  attack 
on  Liege. 

Grenades  are  explosive  bombs  thrown  by  hand ;  they  are 
spherical  in  shape  and  loaded  with  explosives.    The  grenade 


20  PROJECTILES  FROM  FIREARMS 

is  often  an  improvised  bomb  containing  projectiles  of  every 
shape  and  weight.  The  effect  produced  by  its  fragments 
varies  greatly,  terrible  in  general  at  a  short  distance.  Its 
action  is  quickly  exhausted.  The  explosive  action  of  the 
gases  is  exerted  over  only  a  small  area,  in  which,  however, 
it  produces  great  havoc. 

Ballistic  Data  concerning  Shells. 

Following  the  method  adopted  in  describing  bullets,  we 
shall  now  only  consider  the  data  that  are  of  interest  to  the 
military  surgeon. 

It  may  be  said  that  shells  only  act  through  their  splinters 
or  their  bullets. 

In  the  case  of  the  ordinary  shell  with  cast-iron  walls,  the 
large  fragments  are  almost  exclusively  supplied  by  the  rear- 
piece,  the  ogive,  and  the  fuse.  Fragments  of  average  size 
weigh  from  loo  to  300  grammes  (1,543  to  4,630  grains) ; 
small  splinters  are  about  the  size  of  a  walnut.  The  present 
steel  shells  eject  from  their  entire  periphery  small  elongated 
splinters,  not  very  thick,  about  i  or  i^  centimetres  (0-39  or 
0-59  inch),  sometimes  they  are  as  large  as  a  pea;  their 
dimension,  however,  may  even  be  that  of  a  small  fragment. 

Fragments  of  these  shells  rapidly  lose  their  velocity. 
The  slightest  obstacle — a  clod  of  earth,  a  helmet,  a  haver- 
sack, etc. — may  serve  as  a  protection  from  them.  The 
Serbians  use  the  shovels  with  which  entrenchments  are 
being  made  ;  the  Bulgarians  use  earth ;  the  French  soldier 
his  knapsack,  which  protects  his  head  and  shoulders,  whilst 
leaving  his  hands  perfectly  free. 

The  French  mitvaille  shell  discharges  416  bullets  of 
25  grammes  (386  grains),  besides  288  disc  fragments, 
weighing  on  an  average  40  giammes  (617  grains). 

The  larger  fragments  of  shrapnel  are  supplied  by  the 
ogive  and  the  rear-part. 


BALLISTIC  DATA  CONCERNING  SHELLS     21 

The  principal  projectiles  of  shrapnel  are  round  hillets, 
from  10  to  15  millimetres  (o'39  to  0*59  inch)  in  diameter, 
of  small  weight,  and  low  velocity ;  they  may  he  compared  to 
the  old  smooth-bore  hillets. 

They  inflict,  in  general,  slight  injuries,  such  as  contusions 
or  incomplete  perforations,  the  projectile  remaining  in  the 
wound,  rather  than  through-and-through  perforations,  and 
their  "  cul-de-sac  "  wounds  are  often  complicated  by  the  pre- 
sence of  foreign  bodies  derived  from  the  soldier's  clothes, 
which  favour  suppuration. 

Fragments  from  the  much  sub-divided  wall  of  an  explosive 
shell  are  usually  broken  up  into  small,  thin,  striated  and 
sharp  lamellae ;  nevertheless,  some  of  them  spread  out 
and  act  like  a  badly  sharpened  knife.  These  fragments  are 
very  small,  and  sometimes  become  localized  in  the  body  as 
if  they  had  been  sown  like  seed. 

Most  frequently  the  shell  explodes  in  the  air  (time  fuse) 
at  more  or  less  distance  above  the  combatants.  The 
distance  separating  the  shell  from  the  ground  is  called 
bursting  height.  When  this  height  is  small,  the  shower  of 
fragments  or  bullets  is  dense,  that  is  to  say,  closely  charged 
with  projectiles,  and  the  velocity  of  these  secondary  pro- 
jectiles is  increased ;  the  shell  then  is  very  deadly.  It 
would  appear  that  it  is  of  very  little  use  when  the  bursting 
height  is  great,  the  shower  of  projectiles  is  then  more  spread 
out,  less  dense,  more  apt  to  produce  wounds,  but  dangerous 
effects  upon  the  human  body  are  less  conspicuous. 

The  shell  with  percussion  fuse,  which  is  rarely  used,  must 
strike  the  ground  before  exploding.  When  it  falls  perpen- 
dicularly, it  either  buries  itself  in  the  earth  or  forms  a 
funnel-like  excavation,  in  which  its  fragments  are  retained. 
If  it  strikes  the  ground  obhquely,  it  rebounds,  gives  off  a 
shower  of  projectiles,  the  marks  of  which  are  shown  on 
the  ground  as  an  elongated  ellipse.  The  splinters  and  the 
bullets  close  to  the  bursting-point  have  a  greater  penetrating 


22  PROJECTILES  FROM  FIREARMS 

force  than  those  from  a  greater  distance.     In  general,  these 
last  are  the  ones  that  cause  wounds. 

The  velocity  of  the  fragments  and  of  the  bullets  at  the 
point  of  explosion  is  that  of  the  shell  at  the  time  of  falling. 
The  velocity  is — 

At  i,ooo  metres  :  422  metres,  French  shell ;  369  metres, 
German  shell. 

At  2,000  metres:  346  metres,  French  shell;  310  metres, 
German  shell. 

At  3,000  metres :  300  metres,  French  shell ;  279  metres, 
German  shell. 

In  the  case  of  the  time-fuse  shell,  this  velocity  is  increased 
by  the  active  power  (vis  viva),  communicated  by  the  charge 
in  the  interior.  With  the  percussion-fuse  shell,  the  bullet 
has  to  travel  over  several  hundred  metres  before  reaching 
the  body  ;  and  during  its  course  in  the  air,  owing  to  its 
shape  and  size,  it  undergoes  great  loss  of  velocity. 

Whether  the  bullets  or  splinters  proceed  from  a  shell 
with  a  percussion  fuse  or  from  a  shell  with  a  time  fuse, 
when  they  penetrate  into  the  tissues  the  large  rounded 
shape  of  the  former,  the  spread  out  and  irregular  shape  of 
the  latter,  considerably  limit  the  power  of  penetration,  as 
the  resistance  of  the  tissues  is  proportional  to  the  square  of  the 
diameters  of  the  projectiles. 

Consequently  J  one  may  say  that  these  bullets  or  splinters  do  not 
possess  half  the  penetrating  power  of  rifle  bullets. 

Explosive  shells  directed  against  obstacles,  but  which 
reach  the  defending  troops,  are  commonly  and  deliberately 
used  at  the  present  time  against  the  enemy.  These  ex- 
plosion shells,  as  well  as  the  ordinary  percussion  shells, 
under  certain  circumstances,  may  loosen  and  hurl  about 
stones  and  debris  that  play  the  part  of  accessory  projectiles. 

Explosive  shells  are  often  productive  of  multiple  wounds. 
Six,  seven,  ten,  and  more,  have  been  observed  in  one 
wounded  m.an. 


CHAPTER  III 
WOUNDS  OF  DIFFERENT  TISSUES 

The  injuries  inflicted  by  bullets  on  the  soft  parts  are  very 
frequent.  This  frequency  is  a  factor  of  great  importance  to 
the  army  surgeon,  who  has  to  take  it  into  consideration  in 
the  preparation  and  distribution  of  dressings  when  arranging 
for  transport,  and  making  a  computation  of  invalided  men 
and  of  those  who  return  to  duty.  -       - 

The  percentage  of  the  injuries  of  the  soft  parts  is 
estimated  at  about  45  or  50.  The  percentage  even  rose 
to  80  during  the  American  War.  Fischer  stops  at  65  per 
cent. 

Injuries  of  the  Soft  Parts  due  to  Bullets. 

We  will  first  study  the  injuries  caused  by  rifle  bullets. 
The  division  here  adopted  should  be  maintained  in 
statistics. 

Contusions. — These  are  produced  by  spent  bullets  or 
tangential  firing,  frequently  also  caused  by  bullets  from  a 
shell.  Contusions  may  be  very  slight,  or  they  may  end  in 
sloughing. 

Erosions,  Furrows,  result  from  tangential  rifle  fire — 
small  scratches — at  the  level  of  which  the  skin  dries  up 
and  becomes  covered  with  a  brownish  pellicle ;  no  cica- 
tricial trace  is  then  present.  Sometimes  these  are  cutaneous 
abrasions  more  or  less  extensive,  occasionally  5,  6,  or  7  centi- 
metres long  and  2   or  3  centimetres  wide,  owing  to  the 

23 


24  WOUNDS  OF  DIFFERENT  TISSUES 

retraction  of  the  skin,  showing  regular  or  contused  per- 
pendicular edges.  Their  deeper  part  is  formed  of  cellular 
or  muscular  tissue  ;  they  leave  cicatrices. 

Cul-de-sac  Wounds  are  due  to  the  action  of  bullets  of 
low  velocity  which  have  frequently  ricochetted.  They 
leave  a  blind  track  more  or  less  deep,  generally  containing 
the  projectile  that  has  caused  the  wound.  When  the  track 
is  short,  the  bullet  may  have  been  displaced  by  some  move- 
ment or  by  the  removal  of  the  clothes. 

The  cutaneous  aperture  of  entry  is  generally  of  less 
dimensions  than  the  diameter  of  the  projectile — it  is  per- 
fectly round  or  oblique ;  on  the  contrary,  it  is  large  and 
irregular  v/hen  caused  by  a  bullet  that  has  been  deflected 
before  striking  the  body. 

Setons  are  perforations  that  go  through  and  through. 
We  will  now  study  their  apertures  and  track. 

The  aperture  of  entry  varies  in  aspect :  sometimes  it  is 
rounded,  circular  (in  point-blank  fire),  with  an  apparent 
diameter  much  smaller  than  that  of  the  projectile ;  there 
is  loss  of  substance.  On  other  occasions,  especially  with 
pointed  bullets,  it  is  punctiform,  and  so  narrow  that  it  is 
difficult  to  identify  it.  It  has  been  compared  to  a  flea-bite. 
More  often  than  not  it  is  soiled  by  the  projectile  that  in 
passing  has  rubbed  off  against  it  the  impurities  gathered 
during  its  course ;  the  epidermis  has  been  destroyed,  and 
the  derma  bruised  around  the  apertures.  At  times  it  is 
contaminated  by  shreds  of  clothing  that  have  penetrated 
farther  than  its  edges.  As  to  its  dimensions,  they  vary,  in 
general,  with  the  velocity  of  the  bullet.  They  are  a  little 
larger  with  short  distances,  a  little  smaller  with  middle, 
and  insignificant  with  long  ranges.  They  are  also  larger 
when  the  integument  lies  on  a  resistant  plane,  and  smaller 
when  the  skin  can  be  depressed.  When  the  bullet  strikes 
obliquely,  the  aperture  of  entry  is  increased  in  size,  oval 
or  elliptical  in  shape,  with  bruised  edges. 


INJURIES  OF  SOFT  PARTS  DUE  TO  BULLETS    25 

The.  tension  of  the  tissues,  the  position  of  the  limb,  the 
direction  of  the  cutaneous  folds,  may  modify  its  shape. 

The  aperture  of  exit  is  nearly  always  irregular,  and  shows 
in  the  form  of  a  cleft,  which  may  be  either  simple  or 
radiated,  and  is  sometimes  circular  and  punctiform.  It 
appears  larger  than  the  aperture  of  entry,  but  in  reality  it 
is  smaller,  as  it  is  probable  that  the  skin  has  been  much 
distended  before  being  perforated.  Now  and  then  its  edges 
are  everted,  and  not  bruised  like  those  of  the  aperture 
of  entry.  The  dimensions  are  commonly,  although  not 
regularly,  proportional  to  the  velocity  of  the  bullet — that  is 
to  say,  inversely  proportional  to  the  distance  of  the  firing. 

Under  the  loosened  integument  a  little  pouch  filled  with 
blood  sometimes  forms  Pirogoff's  pouch. 

Track. — In  the  great  majority  of  cases  the  track  may  be 
represented  by  a  straight  line  uniting  the  apertures  of  entry 
and  of  exit,  always  supposing  the  limb  or  the  trunk  to  be  in 
the  same  position  as  at  the  time  when  hit  by  the  bullet. 

The  lamince  or  accimitUations  of  cellular  tissue  that  the  bullet 
meets  with  are,  according  to  the  velocity  of  the  projectile 
and  to  their  nature,  freely  perforated  (lamince),  or  only 
dissociated  {accumidations) ;  the  paniculate  masses  of  adjoin- 
ing adipose  tissue  then  fill  up  where  there  has  been  a  loss 
of  substance,  thus  forming  an  aseptic  occlusion. 

Superficial  fascicd  are  wounded,  and  present  circular  or 
oblique  apertures,  when  the  velocity  of  the  bullet  is  great ; 
but  with  average  or  low  rates  of  velocity,  only  the  trans- 
versal or  uniting  fibres  are  dissociated.  The  longitudinal 
fibres  become  forced  apart,  and,  as  we  have  before  demon- 
strated (and  the  fact  carries  very  great  interest),  the  wound 
is  no  longer  represented  by  a  loss  of  substance,  but  by  what  re- 
sembles an  incision,  a  sort  of  button-hole-like  slit  with  retmited 
edges.  These  aponeurotic  button -holes  sectire  the  occlusion  0 
the  track. 

In  muscles  the  track  is  always  cylindrical,  widened  in  the 


2  6  WOUNDS  OF  DIFFERENT  TISSUES 

living  by  muscular  contraction,  filled  up  with  blood,  exuda- 
tion, and  inflammatory  swelling.  The  track  is  larger  than 
the  diameter  of  the  projectile.  Its  size  varies  with  the 
velocity  of  the  bullet,  as  is  the  case  with  other  tissues. 
In  close-range  firing  the  track  is  much  larger  than  in 
middle  ranges,  and  still  more  than  in  long  ranges.  Tracks 
in  muscles  are  narrower  when  the  bullet  is  pointed  than 
when  its  apex  is  flattened ;  the  fissures  they  cause  are 
typical  when  the  firing  is  point-blank. 

When  the  track  follows  the  direction  of  the  muscular 
fibres,  it  is  not  an  easy  matter  to  find  its  course  on  the  dead 
body  (Ferraton). 

By  reason  of  their  mobility,  their  elasticity,  their  shape, 
and  of  their  being  made  up  of  linear  fibres,  tendons  are,  of 
all  tissues,  the  ones  that  ofl"er  the  most  successful  resistance 
to  the  action  of  the  bullets.  Being  loose  in  their  sheath, 
they  are  displaced  and  eroded ;  if  they  are  more  or  less 
fixed,  they  are  indented  and  lineally  perforated. 

Exceptionally  they  are  completely  divided,  but  it  is 
doubtful  whether  this  can  occur  with  pointed  bullets.  This 
question  must  be  further  studied  at  autopsies.  To  sum  up, 
the  track  modern  bullets  make  in  the  soft  parts,  as  it  was 
with  the  old  bullets,  is  irregularly  cylindrical.  It  shows 
constrictions  at  the  level  of  the  linear  aponeurotic  slits, 
and  even  irregularities  at  the  level  of  the  thick  cellular 
layers,  and  of  the  tendons  that  have  only  been  displaced. 
It  is  filled  with  a  magma  of  broken-down  soft  tissues  and 
with  blood.  Infiltrations  of  blood  and  histological  fissura- 
tion  have  been  noticed  a  few  millimetres,  even  a  few  centi- 
metres, from  the  course  followed  by  the  bullet. 

Theoretically,  when  the  velocity  of  the  bullet  is  very 
great,  the  dimensions  of  the  track  should  increase  as 
it  approaches  the  aperture  of  exit ;  but  the  layers  of 
aponeurosis  generally  resist  the  divulsive  and  progressive 
action  of  the  projected  particles  of  tissue  by  arresting  them 
on  their  passage. 


INJURIES  OF  SOFT  PARTS  DUE  TO  BULLETS    27 

The  track  is  more  especially  enlarged  in  the  case  of 
bullets  that  have  tipped  up  and  have  remained  in  the 
tissues.  It  is  still  more  enlarged,  but  in  this  case  from  one 
end  to  the  other,  when  the  bullet  has  ricochetted  on  the 
ground  before  reaching  the  injured  part,  or  when  it  strikes 
obliquely  or  sideways.  When  deflected  in  the  midst  of  the 
tissues  its  track  is  irregular. 

Enfilade  Wounds. — Certain  tracks  are  greatly  extended 
when  the  firing  is  from  above  downwards  or  from  below 
upwards,  as  in  cases  in  which  hills,  buildings,  or  houses  are 
attacked.  One  frequently  sees  that  a  bullet  under  these 
circumstances  has  pierced  for  itself  a  course  from  the  neck 
to  the  buttocks,  from  the  hip-joint  to  the  lower  part  of  the 
leg,  etc.  Under  normal  conditions  of  firing  one  finds  that 
the  bullet  may  have  travelled  a  considerable  distance 
through  different  segments  of  the  same  upper  limb,  fore- 
arm, axilla,  etc.  The  prone  horizontal  position  that  is 
frequently  assumed  by  the  infantry  soldier  in  the  intervals 
during  the  rapid  advances  that  bring  him  nearer  to  the  enemy 
renders  his  body  liable  to  be  wounded  over  a  lengthy 
extent,  and  explains  why,  even  under  ordinary  conditions, 
enfilade  wounds  have  become  very  frequent. 

A  great  many  tracks  are  multiple,  either  caused  by  several 
projectiles,  by  fragments  of  bullets  broken  up  by  having 
ricochetted  near  the  wounded  man,  or  by  the  same  bullet 
having  successively  perforated  two  different  parts  of  the 
body — arm  and  thorax,  arm  and  forearm,  both  right  and 
left  thigh,  etc.  We  must  bear  in  mind  when  the  velocity 
of  the  bullet  is  very  great,  the  second  track  is  often  larger 
than  the  first. 

When  the  soft  tissues  are  the  only  ones  involved,  no 
explosive  lesions  are  observed  from  pointed  bullets  fired  at 
short  range.  Nevertheless  they  may  occur,  especially  in 
tendinous  regions. 

Wounds  of  the  soft  tissues,  inflicted  by  projectiles  from 


28  WOUNDS  OF  DIFFERENT  TISSUES 

modern  rifles,  are  not  painful ;  many  of  them  bleed  suffi- 
ciently to  stain  the  clothing. 

Wounds  from  Revolver  Shots. — They  are  analogous 
to  the  injuries  of  rifle  bullets.  The  apertures  and  tracks 
are  narrow ;  no  explosive  effects  are  noticed  in  their  case. 
The  projectile  often  remains  in  the  wound. 

Injuries  inflicted  by  Bullets  from  Shells  and  by 
Small  Shell  Splinters. — The  round  balls  from  shrapnel, 
like  rifle  bullets,  cause  simple  contusions,  cul-de-sac  wounds 
and  setons,  which  may  be  compared  with  the  wounds  from 
rifle  bullets  ;  the  description  of  the  former,  therefore,  may 
refer  also  to  the  latter.  Contusions  are  very  frequent,  as 
also  cul-de-sac  wounds,  in  which  the  bullet  and  foreign 
bodies  derived  from  the  clothes  remain  in  the  wound. 

Cul-de-sac  wounds  are  usually  pretty  superficial ;  their 
apertures  and  track,  like  those  of  the  setons,  are  larger  and 
more  gaping  than  is  the  case  with  rifle  bullets.  They 
resemble  the  bullet  wounds  of  old  times.  The  wide  gaping 
of  these  wounds  and  the  presence  of  foreign  bodies^  chiefly  derived 
from  the  clothes,  tend  to  facilitate  their  infection. 

Evolution  and  Progress  of  Wounds  of  the  Soft 
Tissues. — Most  wounds  of  the  soft  tissues  by  rifle  bullets 
heal  by  first  intention,  without  a  trace  cf  suppuration,  or 
else  with  a  slight  and  passing  secretion  from  the  contused 
cutaneous  aperture  of  entry.  These  wounds  are  quickly 
covered  by  a  small  protecting  darkish  scab,  due  to  the 
drying  up  of  the  blood-clot,  under  which  cicatrization  takes 
place.  Our  modern  methods  of  dressing  powerfully  contri- 
bute to  this  healing ;  but  as  ii  was  observed  to  take  place 
even  before  the  adoption  of  modern  methods  of  treatment, 
and  as  at  present  it  is  frequently  noticed  in  patients  in  whose 
case  treatment  by  a  surgeon  has  been  impossible,  or  who 
have  even  been  badly  dressed,  we  are  forced  to  admit  that 
other  reasons  must  be  brought  forward  to  explain  so 
favourable  a  result.     At  one  time  it  might  be  considered 


INJURIES  OF  SOFT  PARTS  DUE  TO  BULLETS    29 

due  to,  surgeons  having  abandoned  septic  and  frequent 
explorations  of  the  wound ;  but  to-day  it  is  atrributed  to  the 
ever-increasing  narrowness  of  the  wounds^  in  consequence  of  the 
small  diameter  and  of  the  shape  of  the  bullet,  to  the 
extremely  slight  gaping  of  the  wound,  to  the  much  less  frequent 
presence  of  foreign  bodies,  and,  above  all,  to  a  fact  upon  which 
we  have  dwelt  again  and  again — the  occlusion  of  the  track  at 
the  level  of  the  aponeurotic  septa. 

Long  discussions  have  taken  place  on  the  primary  and 
direct  contamination  of  the  wound  by  the  bullet  and  the  dirt 
with  which  the  projectile  may  be  coated,  by  the  shreds 
and  pieces  of  clothing  which  it  may  carry  with  it ;  also  on 
indirect  contamination  by  contact  with  the  wearing  apparel, 
with  the  patient's  fingers,  or  with  the  fingers  of  those  of  his 
comrades  who  may  have  administered  first  aid.  To-day  the 
problem  is  solved.  To  sum  up,  the  germs  carried  along  by 
a  bullet  are  not  pathogenic,  and  the  bullet  itself  does  not 
infect ;  the  contamination  brought  by  the  clothing  is  anni- 
hilated by  the  defence  set  up  by  the  tissues.  Besides,  a 
wound  infected  by  a  bullet,  especially  by  a  pointed  bullet, 
having  an  average  velocity,  fired  point-blank,  carrying  with 
it  no  large  foreign  bodies  derived  from  clothing,  is  in  the 
very  best  condition  for  spontaneous  healing.  Dressing  but 
affords  a  fresh  guarantee  to  a  natural  tendency  towards 
cicatrization. 

Aseptic  evolution  is  frequent,  especially  in  cases  of 
narrow  wounds  ;  but  large  wounds,  such  as  those  resulting 
from  a  bullet  that  has  been  deflected  by  touching  the 
ground,  wounds  soiled  or  contaminated  by  large  pieces  of 
clothing,  wounds  that  have  remained  a  long  time  in  contact 
with  clothing,  or  that  have  been  badly  dressed  and  badly 
looked  after,  are  all  subject  to  suppvtration,  and  therefore  must  be 
carefully  watched.  The  evolution  of  such  wounds  will  then 
be  either  relatively  aseptic  or  decidedly  septic. 

In  the  first  case  there  will  be  slight  suppuration  of  the 


30  WOUNDS  OF  DIFFERENT  TISSUES 

cutaneous  apertures  and  of  the  track.  Slight,  but  not  pain- 
ful, swelling  of  the  soft  tissues  will  be  noticed  at  first ; 
next,  a  slightly  indurated  cord-like  feeling  will  be  found 
along  the  track,  after  which  the  natural  condition  will  be 
re-established  ;  the  muscles  will  recover  their  suppleness, 
healing  will  take  place  without  consecutive  disturbance. 
Such  is  an  ordinary  course  of  wounds  resulting  from  infected 
bullets,  but  these  wounds  must  have  been  watched  and 
treated  by  capable  surgeons,  having  a  good  armamentarium, 
in  good  sanitary  quarters,  and  provided  the  wounded  men 
present  normal  organic  resistance. 

In  the  second  case — and  the  condition  is  customary  in 
wounds  due  to  shrapnel  bullets,  to  shell  splinters,  to  bullets  deflected 
by  contact  with  the  ground,  or  in  wounds  badly  dressed,  and  whose 
apertures  are  plugged  by  some  foreign  body — suppuration  takes 
place.  It  is  more  or  less  abundant,  sometimes  foetid  ;  it  is 
accompanied  by  tension  and  redness  of  the  limb ;  the  pus 
extends  and  burrows.  Certain  cases  develop  a  diffuse 
phlegmon. 

Wounds  inflicted  by  shrapnel  or  by  small  shell  splinters, 
generally  show  rapid  formation  of  pus,  with  more  or  less 
intense  local  reaction,  which  usually  quickly  yields  to  anti- 
sepsis at  the  seat  of  the  mischief,  to  free  incision,  and  to 
removal  of  foreign  bodies,  either  metallic,  or  composed  of 
pieces  of  clothing. 

To  recapitulate  :  From  a  general  and  practical  point  of  view, 
the  wound  by  a  rifle  bullet  may  be  considered  as  aseptic. 

Many  of  these  wounds  become  infected  and  threaten  suppuration. 

The  greater  number  heal  naturally. 

Healing  takes  place  in  a  few  days  or  weeks. 

Wounds  by  shrapnel  or  by  small  shell  splinters  usually  sup- 
purate. 

Very  large  and  extensive  wounds  that  are  lacerated, 
bruised,  and  frequently  very  dirty,  and  result  from  large 
fragments  of  shell,  the  lesion  containing  or  not  containing  the 


INJURIES  OF  SOFT  PARTS  DUE  TO  BULLETS    31 

body  that  has  caused  the  mischief,  are  hopelessly  doomed 
TO  SUPPURATION.  Healing  is  obtained  after  eHmination  of  the 
scabs  and  when  the  wound  has  granulated.  Local  and 
general  phenomena  of  reaction,  sometimes  very  intense, 
subside  rapidly  if  the  wound  is  dressed  with  a  solution  of 
hydrogen  peroxide.  When  the  wound  has  been  cleaned,  its 
size  may  be  reduced  by  means  of  careful  bandaging,  or  by 
means  of  U-shaped  mediate  sutures. 

Treatment. — The  first  treatment  of  bullet  wounds  in  the 
soft  tissues  consists  in  carrying  out  the  indications  that 
Ferraton  has  so  well  recapitulated  : 

1.  Do  not  touch  the  apevtuves. 

2.  Do  not  explore  the  wound. 

3.  Carry  out  the  dry  toilet  of  the  skin  by  means  of  an  aseptic 
swab  which  may  be  wrung  out  in  alcohol  or  in  tincture  of 
iodine. 

4.  Apply  the  ordinary  dressings. 

Occlusion  of  the  apertures,  suturing,  incisions  to  relieve  con- 
striction in  the  wound,  must  all  be  avoided. 

For  first  aid  to  bullet  wounds  the  dressings  contained  in 
the  packet  each  soldier  carries  will  suffice.  As  a  rule  the  first 
dressing  should  be  applied  at  the  part  of  the  field  where  the 
man  has  been  wounded,  or  at  the  first  aid  station. 

Individual  Dressing-Packet  carried  by  the  French 
Soldier. — These  packets  are  of  various  patterns.  The  old 
pattern  has  two  wrappers  of  ordinary  canvas,  then  a  water- 
proof covering,  partly  tacked  together,  partly  stuck  together, 
which  protects  the  contents  from  external  impurities  and 
from  humidity. 

Each  packet  contains  (i)  a  square  piece  of  gauze;  (2)  a 
square  piece  of  purified  tow  surrounded  by  gauze ;  (3)  a 
cotton  bandage  ;  {4)  two  safety-pins. 

The  gauze  and  the  tow  are  antiseptic ;  they  are  impreg 
nated  with  bichloride  of  mercury. 

Events  have  not  allowed  us  to  completely  replace  the  old 


32  WOUNDS  OF  DIFFERENT  TISSUES 

packets  by  the  new  model,  which  differs  from  the  former 
one  — 

1.  In  the  solidarity  of  the  different  pieces. 

2.  It  guarantees  the  dressing  of  two  wounds  at  a  distance 
from  one  another. 

3.  It  is  aseptic. 

The  contents  of  the  new  model  are  wrapped  in  Japanese 
paper,  which  is  strong,  waterproof,  and  at  the  same  time 
very  light. 

The  packet  is  opened  by  pulling  on  a  small  linen  tape 
which  projects  from  one  of  its  corners. 

It  contains  two  dressings  ;  each  consists  of  a  pad  of  hydro- 
phyllous  cotton-wool  enveloped  in  gauze.  One  of  these 
dressings  is  fixed,  being  sewn  to  the  linen  bandage  destined 
to  bind  up  the  w^ounded  limb ;  the  other  is  movable,  and 
slides  along  the  bandage  by  means  of  two  tapes. 

The  materials  forming  this  second  dressing  have  been 
sterilized  in  the  autoclave,  and  render  unnecessary  the  use 
of  an  antiseptic. 

The  solidarity  of  the  various  parts  forming  the  dressing 
facilitates  its  application  and  diminishes  its  risks  of  being 
contaminated.  In  order  to  better  insure  it  against  contamina- 
tion, two  distinct  signs  (a  red  cross  and  a  black  cross, 
surrounded  by  a  circle)  mark  the  places  where  the  dressing 
should  be  taken  up,  one  sign  for  the  right  hand  and  one  for 
the  left.  To  displace  the  movable  dressing  without  soiling 
it,  a  little  red  tag  will  be  found  sewn  on  one  of  its  corners 
by  which  it  should  be  held. 

It  is  impossible  for  us  to  lay  too  much  stress  on  the  fact 
that  the  individual  dressing  is  "  a  reserve  supply  of  material 
for  ready  use  carried  by  the  wounded."  As  a  general  rule 
the  dressing  should  not  be  applied  by  the  wounded  man 
himself,  nor  by  his  comrades,  nor  by  a  N.C.O.  ;  it  should 
be  applied  by  a  medical  man,  or  by  a  trained  member  of 
the  Army  Medical   Service.      This  is  undisputable ;  it  is 


INJURIES  OF  SOFT  PARTS  DUE  TO  BULLETS    33 

better  not  to  dress  a  wound  at  all  than  to  dress  it  badly, 
and  it  is  as  well  to  look  upon  with  suspicion,  and  as 
necessitating  a  fresh  application,  any  dressing  that  has  not 
been  carried  out  by  a  competent  person  (H.  Billet).  The 
necessity  of  a  preliminary  disinfection  of  the  skin  renders  a 
new  dressing  imperative. 

Dressings  must  be  directly  applied  to  the  skin,  the 
clothes  having  been  unstitched  or  cut  open  into  strips  so  as  to 
expose  the  wound  and  its  surrounding  parts ;  this  should  be 
the  exclusive  duty  of  a  surgical  attendant.  Another  atten- 
dant should  open  the  packets  containing  the  dressings. 
The  man  who  dresses  the  wound  should  first  carefully  dis- 
infect his  hands ;  washing  the  hands  with  soap  is  less 
practical  than  immersing  them  during  three  minutes  in 
alcohol  at  90°,  or,  if  necessary,  in  methylated  spirit,  con- 
taining per  litre  5  c.c.  of  i  in  10  tincture  of  iodine  (the 
whole  solution  being  i  in  2,000). 

When  we  wish  to  disinfect  the  circumference  of  the 
wound  with  iodine- — an  excellent  plan,  and  one  which  is 
held  in  high  esteem  in  the  surgical  practice  of  all  armies — 
the  above  application  should  be  made  dry,  without  previous 
cleansing  with  soap,  water,  alcohol,  or  ether,  etc.  One 
single  coating  with  iodine  will  suffice.  More  than  one  layer 
would  be  useless,  or  might  even  be  injurious.  Friction  of 
any  kind  should  be  avoided. 

For  the  cheeks,  the  eyelids,  or  the  genital  organs,  diluted 
tincture  of  iodine  should  be  used ;  for  all  other  regions  of 
the  body  the  pure  tincture  should  be  employed.  Acci- 
dents, brought  about  occasionally  by  tincture  of  iodine, 
such  as  erythema,  vesication,  excoriation,  or  ulceration, 
are  chiefly  due  to  the  applications  having  been  made  over 
too  extensive  a  surface  or  too  plentifully,  to  frictions 
having  been  carried  out,  or  to  antiseptic  reaction,  but  also 
to  the  use  of  tincture  of  iodine  that  age  has  rendered  stale. 

The  medical  staff  is  now  provided  with  unalterable  tinc- 

3 


34  WOUNDS  OF  DIFFERENT  TISSUES 

ture  of  iodine  (Courtot),  of  easy  transport,  thanks  to  its  having 
been  compressed  (Pellerin).  The  compressed  tincture  is 
instantly  dissolved  in  alcohol  at  95°,  each  block  being 
made  up  so  as  to  give  a  solution  of  i  in  20,  which  is  not 
caustic. 

Robert  and  Carriere  have  enclosed  sublimated  iodine  in 
glass  ampullae.  When  required,  the  ampulla  is  broken, 
its  contents  poured  into  an  accompanying  tube  containing 
alcohol  at  95°  in  sufficient  quantity  to  obtain  tincture  of 
iodine. 

Tincture  of  iodine  is  at  present  the  best  and  safest  disinfectant 
to  make  use  of  in  the  practice  of  war  surgery^  both  in  the  fighting 
line  and  in  the  rear. 

Bichloride  of  mercury  and  carbolic  acid,  with  which  the 
individual  packets  of  the  old  pattern  were  impregnated,  like 
most  of  the  individual  dressings  in  use  in  different  armies, 
render  the  patient  liable,  when  tincture  of  iodine  is  used — 
an  antiseptic  to  which  preference  is  given  nowadays  for 
first  aid  treatment  of  a  wound — to  symptoms  of  irritation, 
which  are  but  rarely  observed  with  a  simple  aseptic 
dressing. 

In  the  Manchurian  campaign  these  symptoms  of  irrita- 
tion were  so  pronounced  that  the  Russians  and  the  Japanese 
who  made  use  of  bichloride  of  mercury  dressings  were  obliged 
to  give  up  tincture  of  iodine  for  the  disinfection  of  wounds. 

We  have  been  able  to  verify  on  wounded  men  in 
the  present  war  the  cutaneous  irritation  pointed  out  by 
the  Russian  surgeons.  The  difficulty  might  be  overcome 
and  these  untoward  incidents  avoided  by  first  of  all  applying 
under  the  dressing  a  little  square  of  folded  gauze ;  this 
should  be  done  at  the  collecting  and  first  aid  stations.  The 
first  dressing  of  the  wound  will  generally  be  held  in  place 
by  the  bandage  contained  in  the  packet.  An  extra  bandage 
will  make  the  dressing  more  secure. 

In  the  ambulances  in  the  rear,  where  the  dressing  has  lost 


INJURIES  OF  SOFT  PARTS  DUE  TO  BULLETS    35 

the  fixity  it  had  at  the  front,  the  use  of  adhesive  rubber  spara- 
drap,  of  the  leucoplastic  or  vulvoplastic  type,  has  been  ad- 
vised. Personally,  we  have  not  been  satisfied  with  the  results 
we  have  seen  of  this  method. 

There  are  counter  indications  to  repeated  dressing  of 
wounds  of  the  soft  parts  produced  by  bullets  ;  these  lesions 
are  very  slight,  and  already  present  conditions  most  favour- 
able for  spontaneous  healing. 

We  have  already  seen  that  wounds  by  ricochetted 
bullets  are  subject  to  symptoms  of  suppuration  coming  on 
very  rapidly.  After  incisions  have  been  made  dressings 
will  be  applied  of  the  usual  topical  remedies.  Hydrogen 
peroxide  here  is  particularly  worthy  of  recommendation  for 
the  first  consecutive  dressing.  Strong  carbolic  acid  solu- 
tions, touching  the  wound  with  a  i  in  10  solution  of 
chloride  of  zinc,  iodine  by  instillation,  or  by  simple  applica- 
tion, instillations  of  ether,  etc.,  are  all  of  great  use.  We 
must  not  forget  that  these  wounds  are  often  complicated  by 
foreign  bodies  derived  from  the  clothes,  or  by  the  presence 
of  the  bullet  itself ;  in  such  cases  the  only  topic  to  be  employed 
is  hydrogen  peroxide. 

The  wounds  we  are  now  considering  are  among  those  in 
which  there  is  always  a  danger  of  tetanus  and  of  emphy- 
sematous gangrene ;  hydrogen  peroxide  is  known  to  be 
a  toxic  for  anaerobic  microbes,  which  are  the  provocative 
agents  of  these  complications. 

The  same  principles  should  be  followed  acd  the  same 
methods  applied  in  dressing  extensive  wounds  of  the  soft 
tissues  resulting  from  shrapnel  or  shell  fragments.  We 
will  not  dwell  upon  this  subject  at  present,  as  we  shall 
have  to  consider  it  again  in  dealing  with  complications. 


CHAPTER  IV 
LESIONS  OF  THE  VESSELS 

Wounds  of  Arteries. 

Judging  from  the  medical  history  of  warfare,  wounds  of 
the  large  vessels  are  rare  ;  but,  on  the  other  hand,  post- 
mortem examination  has  shown  that  they  are  very 
frequent  (Delorme,  Chauvel,  Fessler).  Their  extremely 
serious  nature  is  the  explanation  of  the  rarity  of  cases 
which  have  been  observed  and  subsequently  published. 
There  are  new  and  precise  data  to  be  contributed  with 
regard  to  their  total  as  well  as  their  relative  ratio. 

With  the  Gras  and  Lebel  bullets,  in  the  great  majority 
of  cases,  when  the  projectile  encountered  arteries  in  its 
course,  it  either  broke  through  them  or  bruised  them. 
Their  elasticity,  their  mobility,  the  fluid  nature  of  their 
contents,  hardly  ever  allowed  them  to  escape  from  the 
action  of  the  bullet.  It  was  the  same  with  the  G  bullet 
during  the  Balkan  War. 

The  lesions  seen  in  arteries  are — Contusions,  lateral 
wounds,  perforations,  and  section. 

Contusions. — They  are  reported  less  exceptionally  than 
wounds,  because  overwhelming  haemorrhage  is  not  here  a 
fatal  consequence. 

Three  degrees  of  contusions  may  be  noted  : 

In  the  first  degree  the  artery  is  ecchymosed  on  its  surface, 
and  in  its  interior  it  exhibits  slight  fine  transverse  lacera- 

36 


WOUNDS  OF  ARTERIES  37 

tionSj  which  look  as  if  they  had  been  produced  by  the  point 
of  a  pin.  These  solutions  of  continuity  correspond  to  the 
horizontal  interstices  in  the  muscular  and  elastic  fasciculi 
of  the  middle  coat  of  the  artery.  The  contusion  is  there- 
fore represented  by  a  series  of  internal  wounds. 

If  the  middle  coat  is  deeply  and  transversely  fissured  at 
points  corresponding  to  where  the  bullet  has  passed — if  it 
shows  what  is  really  an  internal  wound  which  is  localized 
and  irregular — then  we  have  the  second  degree. 

In  the  third  degree  there  are  deep  lesions  exhibiting  the 
same  characteristics  ;  however,  they  are  no  longer  localized, 
but  extend  over  the  whole  lumen  of  the  vessel.  The  out- 
side of  the  artery  is  more  ecchymosed,  and  the  vessel  is 
narrowed  at  the  wounded  part. 

Knowledge  of  these  facts  is  very  important.  If,  strictly 
speaking,  in  the  first  degree  the  formation  of  an  obliterating 
clot  is  not  fatal  (Matthew),  the  same  thing  is  certain  to 
occur  in  the  two  last,  and  the  friction  to  which  the  arterial 
wall  has  been  exposed  renders  it  liable  to  gangrene.  Yet 
in  the  last  degree  the  complete  rolling  up  of  the  inner  coats 
makes  the  clot  much  firmer  than  in  the  second  degree. 

These  contusions  therefore  can,  especially  in  aseptic 
wounds,  be  of  no  consequence  (first  degree) ;  they  may 
cause  obliteration  of  the  artery,  local  ischgemia,  and  dis- 
appearance of  the  pulse  of  the  vessel ;  they  may  be  followed 
by  the  formation  of  a  scab,  especially  in  septic  wounds ; 
or  they  may  be  followed  by  consecutive  terrible  haemor- 
rhages ;  and,  lastly,  they  may  give  rise  to  the  formation  of 
an  aneurysm. 

There  are  no  characteristic  features  in  the  troubles  of 
sensation  and  of  motility  caused  by  arterial  contusion ; 
there  is  strong  probability  of  gangrene  occurring  at  a 
distance ;  the  only  sign  of  real  value  is  derived  from — 

I.  The  close  relationship  the  course  of  the  bullet  assumes  with 
the  artery. 


38  LESIONS  OF  THE  VESSELS 

2.  The  disappearance  of  the  arterial  pulse  when  there  has  not 
been  any  considerable  primary  haemorrhage,  and  no  aneurysm  has 
been  noticed. 

These  signs  are  valuable,  because  they  can  be  looked  for 
at  once.  A  wounded  man  who  is  suspected  of  suffering 
from  a  contusion  of  a  large  artery  should  not  be  moved. 

He  must  be  closely  watched.  His  fate  depends  partly  on 
asepsis,  partly  on  a  septic  condition  of  the  wound,  bringing  about 
the  falling  off  of  the  scab. 

It  is  prudent,  if  one  has  any  doubt  concerning  the  asepsis 
of  the  wound,  to  search  for  the  vessel  without  waiting  for 
the  occurrence  of  haemorrhage ;  and  if  it  is  found  to  be 
much  ecchymosed,  and  especially  if  it  is  narrowed,  to 
ligature  it  both  above  and  below  the  contused  part. 

Would  incision  into  the  artery,  turning  out  the  clot  and 
suture  of  the  vessel,  be  of  any  use  ?  (This  operation  has 
been  proposed.)  After  ablation  of  the  clot,  however, 
another  one  would  recur  in  the  same  place  through  contact 
with  the  internal  irregularities  of  the  arterial  wall,  and, 
furthermore,  suture  of  the  contused  wall  certainly  would 
not  hold. 

Lateral  Wounds. — These  consist  of  loss  of  substance 
of  a  curved  shape,  which  may  involve  a  quarter,  a  third 
of  the  transverse  diameter  of  the  vessel.  The  indentation 
is  clean,  sometimes  it  has  fissures  on  its  margins.  All  the 
arterial  tunics  are  divided  on  the  same  level,  and  the  middle 
coat  is  not  retracted. 

Very  superficial  and  slight  scratches,  but  with  no  opening 
into  the  artery,  have  been  described.  When  the  wound  has 
involved  nearly  the  whole  of  the  diameter  of  the  artery, 
owing  to  movements  of  the  injured  limb,  the  vessel  may 
burst ;  this  may  be  regarded  as  a  fortunate  circumstance. 

Complete  Perforation. — Through  and  through  perfora- 
tions, as  well  as  lateral  perforations,  are  often  described  in 
post-mortem  examinations.      They  are  circular  or  nearly 


WOUNDS  OF  ARTERIES  39 

oval,  exceptionally  linear  with  the  Gras  bullets  and  the 
Lebel  bullet,  which  last  is  analogous  to  the  Austrian 
Mannlicher  and  the  German  Mauser  bullets.  With 
pointed  projectiles  will  linear  wounds  become  less  excep- 
tional ?     This  is  a  matter  to  investigate. 

The  edges  are  clean,  scarcely  fimbriated ;  both  above 
and  below  the  lesion  the  internal  tunics  are  not  retracted. 

The  dimensions  of  the  apertures  are  small  or  the  con- 
trary according  to  the  greater  or  less  velocity  of  the 
projectile.  They  are  still  smaller,  with  a  pointed  bullet  of 
small  diameter.  As  a  general  rule,  both  the  walls  of  the 
artery  are  perforated. 

Those  gaping  wounds,  the  spontaneous  plugging  of  which 
was  impossible,  gave  rise  in  former  times  to  awful  external 
haemorrhage  ;  the  blood  poured  freely  from  wounds  with 
large  external  orifices.  Now  that  these  last  contract, 
external  bleeding  is  less  fatal  and  less  abundant;  primary 
false  anettrysms  are  more  often  seen,  and  they  constitute  a  fortunate 
termination. 

Complete  Division. — This  is  more  especially  noticed  in 
small  arteries.  In  the  larger  vessels  it  seems  to  be  caused 
by  the  action  of  bullets  having  a  very  high  velocity. 
Deflected  bullets  and  those  from  shrapnel  very  often 
produce  it.  A  priori,  these  wounds  would  seem  to  be  very 
grave  ;  in  reality  they  are  not  so,  for  the  transverse  tearing, 
the  shreds  and  strips  of  the  middle  coat,  the  fraying  out  of 
the  external  coat  at  the  two  ends  where  the  division  has 
occurred,  promote  the  formation  of  clots  in  the  same  way 
as  the  total  narrowing  of  the  walls  is  consecutive  to  retrac- 
tion of  the  two  segments  of  the  vessel."^ 

*  During  the  Balkan  War  it  was  observed  that  at  short  distances, 
clear  loss  of  substance  of  the  artery,  with  haemorrhage,  took  place  ;  at 
average  distances  there  occurred  lateral  wounds,  more  frequently  per- 
forations, more  rarely  simple  contusions,  complete  sections,  the  vessel 
being  often  contused  and  reduced  to  pulp,  tearing  of  the  artery  when  the 
bullet  came  from  a  cross  direction  ;  at  long  distances  there  were  princi- 
pally contusions. — Ferraton. 


40  LESIONS  OF  THE  VESSELS 

Wounds  of  arteries  the  results  of  the  bursting  of  shells 
present  the  characteristics  of  lesions  caused  by  tearing,  by 
direct  contusion,  by  lateral  perforation  or  section  (sharp- 
pointed  or  linear  fragments).  Small  shell  splinters  might 
produce  linear  perforation.  Shrapnel  bullets  generally 
give  rise  to  contusions  of  arteries,  and  less  frequently  to 
perforation  and  section. 

When  a  limb  is  torn  off  by  large  projectiles  or  their  big 
fragments,  the  vessel,  besides  being  divided,  is  drawn  out 
for  some  distance.  Thus  can  be  explained  the  absence  of 
bleeding,  in  spite  of  the  gaping  of  the  large  arteries. 

Arterial  wounds  caused  by  splinters  thrown  out  by  the 
bursting  of  a  shell  are  beyond  all  description. 

The  close  relations  of  the  large  arteries  to  the  large 
veins  are  the  cause  of  both  vessels  being  often  wounded  at 
the  same  time. 

Symptomatology — Prognosis.  —  Everyone  knows  the 
fundamental  signs  of  wounds  of  arteries  :  hcBmoyvhage  nearly 
always  in  jets  ;  the  bright  colour  of  the  blood.  This  bleeding 
may  be  stopped  by  proximal  pressure  ;  cessation  of  the  pulse  on  the 
distal  side  of  the  vessel. 

The  concomitance  of  arterial  and  venous  wounds  rather 
mars  the  clearness  of  this  description.  Haemorrhage  with 
narrow  wounds  often  becomes  haematoma,  but  this  last 
brings  with  it  a  new  sign — its  pulsation. 

External  haemorrhage^  in  contradistinction  to  what  one 
would  suppose,  is  not  always  of  great  importance  when 
large  vessels  are  affected.  Amongst  twelve  cases  of  lesions 
of  large  vessels  Hildebrandt  and  Kuttner  only  found 
abundant  haemorrhage  six  times^  whilst  there  were  five 
insignificant  haemorrhages  and  one  average  bleeding. 
These  are  ambulance  reports  which  really  only  deal  with  a 
part  of  the  reality.  Wounded  men  with  grave  haemorrhage 
succumb  before  arriving  at  the  ambulance  station  if  their 
external  wounds  are  extensive. 


WOUNDS  OF  ARTERIES  41 

A  fact,  the  result  of  the  experience  acquired  in  recent 
wars,  is  that,  by  reason  of  the  narro.wness  of  the  track  made 
by  the  present  bullets,  and  of  the  antisepsis  or  asepsis  of 
the  wounds,  the  prognosis  of  the  lesions  of  the  large  vessels 
has  been  improved,  a  little,  a  very  little,  without,  however, 
having  become  much  less  unfavourable.  It  is  specially  the 
prognosis  of  wounds  of  average-sized  vessels  that  has  been 
modified. 

Treatment. — i.  On  the  field  of  battle^  at  the  receiving 
and  first  aid  stations,  indirect  digital  compression,  followed  at 
once  by  indirect  mechanical  compression^  are  the  first  methods 
to  employ. 

Indirect  digital  compression  still  retains  its  superiority  for 
wounds  of  the  carotid  and  of  the  subclavian. 

Morel's  garrot  and  Mayor  s  cravat  bandage '''  (cravat  with 
a  knot  which  is  applied  to  the  course  of  the  artery)  are  the 
best  means  of  applying  indirect  mechanical  compression. 
They  only  show  to  disadvantage  when  their  use  is  pro- 
longed, which  is  quite  contrary  to  their  purpose.  They 
should  be  employed  almost  as  makeshifts,  their  application 
being  only  temporary. 

Forced  extension  or  flexion  of  the  limbs  is  helpful  and  useful. 
In  certain  large  wounds  the  surgeon  may  utilize  aseptic 
plugging.  This,  however,  is  disadvantageous  if  left  in  too 
long,  and  if  the  wounded  man  is  lost  sight  of  (Russo- 
Japanese  and  Balkan  Wars). 

If  the  wounded  man  arrives  at  the  ambulance  station  fixed 
up  in  some  apparatus,  or  in  one  that  it  is  possible  to  fix, 
he  should  remain  in  it.  Whatever  the  future  treatment 
decided  upon,  the  patient  must  not  be  transported.  Transport 
renders  the  clots  liable  to  displacement,  and  removes  the 
wounded  man  from  direct  supervision. 

Soldiers  wounded  in  the  chest  during  the  Transvaal  War 

*  This  is  probably  a  modification  of  Mayor's  handkerchief  dressing 
for  fractured  clavicle. — Note  by  Translator. 


42  LESIONS  OF  THE  VESSELS 

were  attacked  with  internal  haemorrhage  and  ha^mothorax 
in  the  proportion  of  90  per  cent,  when  they  were  trans- 
ported from  one  locality  to  another,  and  in  the  proportion 
of  30  per  cent,  when  they  were  kept  at  one  place  (Makins). 

Whatever  the  treatment  made  use  of,  it  should  he  employed  when 
possible  before  the  patient  has  recovered  from  his  condition  of 
syncope,  or  at  any  rate  whilst  he  is  recovering. 

The  first  indications  of  the  so-called  definite  treatment  should  he 
settled  at  the  ambulance.  They  are  transcribed  from,  and 
explained  in,  the  following  lines  taken  from  my  communi- 
cation to  the  Academy,  February  24,  19 14: 

*'  For  a  long  time  the  practice  of  war  surgery  in  cases 
of  wounds  of  the  large  arteries  has  been  reduced  to  the 
two  following  formulae : 

"  I.  The  opening  into  a  large  artery  necessitates,  as 
immediate  treatment,  compression  in  the  interval  before  the 
application  of  a  direct  double  ligature,  that  is  to  say,  one  that 
is  carried  both  over  and  under  the  lesion.  This  ligature 
was  looked  upon  as  an  operation  of  urgency. 

"If  the  haemorrhage  has  ceased  when  the  surgeon  sees 
the  wounded  man,  he  can  either  wait,  keeping  the  patient 
under  close  observation,  or  apply  a  direct  ligature  if  he 
fears  a  recurrence  of  the  haemorrhage. 

**  This  was  the  rule ;  its  carrying  out  had  to  take  the 
risks  which  might  be  set  up  by  the  surroundings  of  the 
case.  In  fact,  immediate  or  rapid  ligatures  of  the  large 
vessels  could  be  counted  by  units  in  the  histories  of  cam- 
paigns, and  in  spite  of  the  large  number  of  well-known  and 
much-talked-of  extemporary  compressors,  first  aid  hardly 
ever  arrived  in  time.  Deaths  through  haemorrhage,  on  or 
close  to  the  field  of  battle,  reached  the  enormous  propor- 
tions that  are  well  known ;  the  blood  so  easily  escaped 
through  the  relatively  large  wounds  made  by  bullets  and 
through  still  larger  orifices  left  by  shells. 

"  The   suppuration    that    invaded    these  wounds,  whilst 


WOUNDS  OF  ARTERIES  43 

giving  ri^e  to  the  displacement  or  the  softening  of  the  clot, 
and,  in  contusions  of  arteries,  to  the  separation  of  the  scab, 
and,  finally,  to  various  other  infections,  consecutively  in- 
creased the  number  of  deaths  through  haemorrhage.  Cases 
of  aneurysm  were  very  rare.  I  had  a  great  deal  of  trouble 
to  find,  for  my  Treatise  on  War  Stirgery,  the  number  of  cases 
of  aneurysm  that  satisfied  me.  Otis,  during  the  American 
Civil  War,  amongst  several  hundred  thousand  cases, 
only  observed  seventy-four ;  and  Pirogoff,  that  veteran  of 
Russian  campaigns,  tells  us  that  he  never  saw  an  arterio- 
venous aneurysm  the  result  of  a  projectile. 

"  First  aid  has  been  better  understood  of  late  years,  but 
of  more  importance  still  are  certain  characteristics  of  the 
wounds  brought  about  by  modern  bullets,  and  also,  we  are 
bound  to  say,  the  more  rapid  and  more  simple  healing  of 
the  external  lesions,  all  these  have  caused,  in  this  terrible 
prognosis  of  wounds  of  the  large  vessels,  a  mitigation  that 
began  to  be  noticed  by  surgeons  during  the  Transvaal  War, 
and  which  continued  to  make  an  impression  on  medical 
men  during  the  Manchurian  and  Balkan  campaigns.  The 
nature  of  the  arterial  and  venous  traumatisms  was  the 
same :  contusions,  indentations  or  lateral  perforations,  central 
perforations  with  a  piece,  as  it  were,  punched  oitt,  that  have  been 
described  by  Lidell  and  me ;  but  where  the  greatest  change 
occurred  was  in  the  narrowness  of  the  course  the  bullet 
made  in  the  thickness  of  the  soft  parts  —  this  facilitated 
spontaneous  hsemostasis. 

*'  Speaking  generally,  the  number  of  cases  of  profuse 
external  haemorrhage  has  diminished,  whilst  that  of  arterial 
haematomata,  of  aneurysms  both  arterial  and  arterio-venous, 
has  increased  sufficiently  to  make  it  imperative  for  surgeons 
to  take  notice  of  the  change  and  to  discuss  the  methods 
of  active  treatment  applicable  to  these  last  conditions. 
Surgeons  were  even,  to  a  certain  extent,  deluded  as  to  their 
degree  of  frequency,  this  being  shown  by  Loison's  formula  : 


44  LESIONS  OF  THE  VESSELS 

in  past  wars  hcEmorrhage  was  frequent  and  aneurysms  were  rare  ; 
in  present  wars  it  has  been  exactly  the  reverse.  The  aneurysms, 
however,  remained  rare.  Bornhaupt,  amongst  3,600  wounds 
seen  in  the  ambulances  at  the  rear,  only  found  8  cases ; 
this  is  a  great  many  compared  with  the  zero  of  former  times, 
but  perhaps  it  is  not  enough  to  warrant  us  having  an 
excessive  confidence  in  the  benefit  conferred  by  the  forma- 
tion of  these  aneurysms,  and,  relying  on  their  possible 
appearance,  to  give  out  as  a  definite  rule  that — 

"7;?  wounds  of  large  vessels  we  must  no  longer  put  on  a  ligatiire 
whilst  the  patient  is  on  or  near  the  field  of  battle,  but  we  must  rest 
content  with  compression  and  with  securing  immobility  of  the  limb. 
The  wounded  man,  transported  at  once  to  the  rear^  and 
placed  in  a  fixed  ambulance  which  he  reaches  after  an 
interval  it  is  impossible  to  specify,  can,  if  necessary,  be 
treated  there  for  his  aneurysm. 

"  This  maxim  was  suggested  to  us  during  the  Manchurian 
War  by  a  surgeon  who  saw  the  wounded  in  the  rear — that  is 
to  say,  that  he  only  saw  a  part  of  the  scene  ;  but  Manteuffel, 
whose  experience,  on  the  contrary,  was  acquired  on  the  field 
of  battle  and  at  the  halting-places  of  the  troops,  had  been 
struck  by  the  grave  nature  of  the  haemorrhages  that 
occurred  under  fire,  and  had  seen  on  the  line  of  march  cases 
of  gangrene  brought  on  and  hastened  by  haemostatic  com- 
pression continued  for  too  long  a  time,  and  finally  hsemor- 
rhagic  relapses  due  to  the  displacement  of  clots  during  the 
transport.  Manteuffel  remained  an  adherent  of  the  practice 
of  rapid  ligature  and  of  keeping  the  patient  immobilized  on 
the  spot.  '  One  must  not  have  seen,'  he  says,  '  these  blood- 
less corpses  abandoned  in  large  numbers  at  every  station 
by  the  convoys  of  wounded  in  order  to  realize  the  gravity 
of  wounds  of  vessels,  in  spite  of  their  apparently  benignant 
nature.' 

"  Such  are  the  sights  the  surgeon  sees,  such  is  the  very 
best  opinion.     It  is  the  one  commonly  adopted  in  everyday 


WOUNDS  OF  ARTERIES  45 

practice.  It  is  one  I  have  always  supported,  however 
difficult  'its  application  during  a  campaign,  and  it  is  the  one 
to  which  we  must  have  recourse.  I  reduce  it  to  the  follow- 
ing formula : 

In  wounds  of  the  large  vessels,  ligatiive  after  compression 
should  remain  an  operation  of  iirgency  for  cases  in  which  the 
haemorrhage  continues ;  if  it  stops,  the  patient  should  be 
immobilized  on  the  spot  and  closely  watched.  Supervision 
would  certainly  be  better  carried  out  in  the  first  hne  than  in 
halting-places  on  the  road  or  on  the  railway.  When  the 
surgeon  considers  the  proper  time  has  arrived,  he  will  send 
the  wounded  man  on  to  the  nearest  hospital. 

We  must  not,  however,  carry  to  an  exaggerated  degree 
the  number  of  the  operations  or  the  length  of  the  super- 
vision, both  of  which  must  be  greatly  limited  by  the  in- 
variably grave  nature  of  wounds  of  the  large  arteries  even 
when  caused  by  small  modern  bullets ;  this  was  proved  by 
the  remarks  of  Brentano  during  the  Manchurian  campaign. 

On  the  other  hand,  we  must  not  forget  that  lesions  of 
arteries  by  projectiles  of  war  are  nearly  always  gaping 
wounds,  with  no  retraction  of  the  arterial  coats ;  for  these 
reasons  they  are  lesions  that  present  very  unfavourable 
conditions  for  haemostasis  and  spontaneous  cicatrization. 

Suture  of  the  arteries  has  been  recommended  of  late  in 
bullet  wounds.  The  large  size  of  the  vessels,  their 
characteristics  derived  from  loss  of  substance,  from  bruised 
edges,  from  infection,  which  is  always  to  be  feared,  the 
knowledge  also  that  suture  can  only  be  successful  in 
absolutely  aseptic  wounds,  all  tend  to  militate  generally 
against  such  a  procedure.  At  most,  in  theory,  this  method, 
with  its  uncertain  results  in  wounds  by  ordinary  bullets, 
seems  admissible  in  those  linear  lesions  (pointed  bullets, 
small  shell  spHnters)  which  are  brought  to  light  during 
attempts  at  ligature. 

Suture  would  certainly  be  more  worthy  of  trial  in  wounds 


46  LESIONS  OF  THE  VESSELS 

of  the  large  veins,  but  bleeding  from  these  last  is  very  much 
less  to  be  feared  than  that  from  the  arteries. 

Carrel's  direct  suture  with  silk,  either  in  form  of  a  U  or 
continuous,  is  to  be  preferred.  Haemostatics  are  only  of  use 
in  arresting  general  oozing  (solutions  of  alum,  concentrated 
alcohol^  antipyrine,  adrenalin,  hydrogen  peroxide,  horse 
serum,  etc.). 

Arterial  haemorrhage  gives  rise  to  acute  anaemia  with 
which  we  must  deal.     We  shall  speak  of  this  later  on. 

Wounds  of  Veins. 

The  walls  of  veins  are  less  fragile  than  those  of  arteries, 
and  are  more  extensible  laterally.  Experiments  have 
demonstrated  that  veins  escape  more  often  than  arteries 
from  the  action  of  projectiles  that  graze  them.  When  the 
accompanying  artery  is  apparently  contused  or  shows  a 
lateral  wound,  the  vein  appears  to  be  intact. 

The  traumatisms  produced  by  bullets  are  conttisions,  lateral 
woimds,  complete  perforations^  or  section. 

Contusions. — Contused  veins  do  not  exhibit  the  lesions 
that  are  so  characteristic  in  arteries.  Whilst  the  external 
coat  presents  evident  signs  of  friction,  we  do  not  see,  in  the 
dead  body,  any  fraying  or  dividing  of  the  internal  coat. 
Circulation  of  blood  is  not  interrupted  in  the  vessel. 

Lateral  Wounds. — These  are  indentations  similar  to 
those  seen  in  arteries. 

Total  Perforation. — The  same  remarks  apply  as  in  the 
case  of  arteries  ;  but  already  with  the  old  bullets  we  find 
the  perforations  were  reduced  in  size,  often  linear  in  shape, 
with  insignificant  contusion  of  the  edges,  and  they  were 
seen  in  vessels  of  smaller  calibre. 

Sections. — Caused  by  unequal  tearing  or  crushing  of  the 
coats  of  the  vessel  at  one  point.  Sometimes  they  are  clean 
sections. 


WOUNDS  OF  VEINS  47 

The  wounds  produced  by  fragments  of  large  projectiles 
are  very  similar  to  the  arterial  lesions,  but  ruptures  at  a 
distance  are  not  seen. 

We  lay  no  particular  stress  on  the  well-known  sign  of 
venous  haemorrhage :  dribbling  of  black  blood,  which  can  be 
stopped  by  distal  compression. 

Contusion  may  be  suspected  when  there  is  neither  haemor- 
rhage nor  sanguineous  suffusion,  and  when  the  track  of  the 
bullet  corresponds  to  that  of  the  venous  trunk. 

In  nearly  all  cases  the  vein  remains  permeable ;  its 
primary  thrombosis  is  rare.  Introduction  of  air  into  veins 
is  a  very  exceptional  complication,  and  only  takes  place  in 
certain  regions.  Arterio-venous  aneurysms,  formerly  very 
rarely  seen,  are  less  exceptional  at  the  present  time. 

Compression  generally  suffices  to  arrest  haemorrhage  of  the 
large  veins.  Ligature  would  only  be  employed  in  cases  of 
very  severe  venous  bleeding  with  extensive  external  wounds, 
or  occurring  in  a  lesion  in  which  we  are  seeking  for  the 
accompanying  artery,  which  also  has  been  wounded. 

Complications  of  Wounds  of  the  Large  Vessels. 

In  the  first  rank  must  be  placed  acute  ancemia^  going  as  far 
as  apparent  death. 

Acute  Anaemia. — To  the  ordinary  signs  that  form  part 
of  the  symptomatology  of  haemorrhage  the  following  may 
be  added  :  Tinnitus  aurium,  dizziness,  shivering,  nausea, 
vomiting,  involuntary  emission  of  urine,  dilatation  of  the 
pupils,  great  acceleration,  and  at  the  same  time  smallness 
of  the  pulse,  great  fall  in  the  temperature,  discoloration,  and 
flabbiness  of  the  integuments,  cold  sweats,  vertigo,  syncope, 
or  great  tendency  to  it.     The  syncope  is  often  providential. 

These  are  the  primary  signs;  later  on  they  may  be  sup- 
plemented by  more  or  less  persistent  general  weakness, 
diarrhoea. 


48  LESIONS  OF  THE  VESSELS 

The  anaemia  is  all  the  more  acute  when  the  loss  of  blood 
has  been  rapid ;  its  influence  on  the  brain  and  on  the 
medulla  oblongata  is  immediate. 

Successive  losses  of  blood  delay  the  healing  of  the  wounds, 
increase  the  tendency  to  suppuration,  and  open  a  way  to 
infection  (Kirmisson). 

HcBmorrhage  having  been  arrested,  we  should  deal  with  the 
syncope  by  making  the  patient  lie  down,  with  the  head  low, 
by  frictions,  flagellation,  artificial  respiration,  inhalations  of 
ether,  etc.,  elevation  of  the  limbs.  If  necessary,  we  can 
make  use  of  suhcutaneous  injections  of  sulphuric  ether  (the  con- 
tents of  one,  two,  or  three  Pravaz  syringes),  of  injections 
of  camphorated  oil,  of  caffeine,  of  injections  of  normal  salt 
solution  (sea-salt  7  per  1,000).  Subcutaneous  injections  of 
normal  saline  are  employed  in  the  least  serious  complications, 
and  intravenous  injections  in  the  most  serious.  These  in- 
jections take  the  place  of  transfusion,  which,  moreover,  it 
would  be  almost  impossible  to  make  use  of  in  war  surgery, 
even  were  it  more  efficacious  and  absolutely  free  from  danger. 

Apparent  Death. — Although  syncope  going  as  far  as 
apparent  death  can  be  produced  by  pain,  violent  moral 
impressions,  cold,  extreme  fatigue,  or  hunger,  it  is  most 
often  caused  by  severe  haemorrhage. 

When  syncope  is  prolonged — and  this  frequently  happens 
— it  might  give  rise  on  the  field  of  battle  to  mistakes,  did 
we  not  make  a  point  at  the  time  of  interment  of  seeking  for 
the  positive  signs  of  death.  When  there  is  the  slightest 
doubt,  the  wounded  man  should  be  left  on  the  spot  where 
he  has  been  found. 

The  following  examples  should  always  be  borne  in  mind 
by  the  military  surgeon  : 

L ,  corporal  in  a  line  regiment,  received  a  bullet  in  the  face, 

and  was  left  for  dead  on  the  Medole  plain.  It  was  only  on  the  follow- 
ing day  when  burying  the  dead  was  being  carried  out  that  signs  of  life 
were  discovered.     L is  now  living  on  his  pension  (Chenu). 


WOUNDS  OF  THE  LARGE  VESSELS         49 

I  experienced,  says  Nusbaum,  an  awful  shock  after  the  Battle  of 
Orleans,' October  10  and  11,  1870,  when,  during  a  gloomy,  cold  and 
dark  night,  I  found  there  were  a  very  large  number  of  cases  of 
lethargy.  Many  times  we  returned  with  four  or  five  stretcher-bearers 
to  wounded  men  who  had  been  left  for  dead,  although  the  beating  of 
their  heart  could  still  be  felt.  After  we  had  brought  them  in,  made 
them  warm,  given  them  food,  we  succeeded  in  bringing  them  back  to 
life.  Loss  of  blood,  exhaustion,  hunger,  cold,  fright,  seemed  to  me  to 
have  been  the  causes  of  the  lethargy.  It  is  dreadful  to  think  that  these 
poor  brave  young  men  could  have  remained  lying  in  a  moribund  condi- 
tion in  the  ditches  at  the  sides  of  the  road  whilst  the  ambulance  men  went 
to  and  fro  without  noticing  them.  There  is  not  the  slightest  doubt  but 
that  lethargy  can  change  into  absolute  death  when  several  hours  elapse 
before  the  wounded  are  attended  to  or  afforded  warmth  (Nusbaum). 

Traumatic  Aneurysms— Arterial  Aneurysms. — Trau- 
matic aneurysms  of  the  arteries  are  seen  under  different 
aspects.  Sometimes  we  see  a  diffuse,  tense  hsematoma 
with  a  souffle  ;  sometimes  a  more  or  less  extensive  hsema- 
toma  which  a  sudden  haemorrhage,  when  compression  is 
taken  off,  has  increased ;  at  other  times  it  is  a  more  or  less 
extensive  infiltration  having  no  souffle,  the  peripheric  pulse 
being  weakened,  but  still  perceptible  (Laurent).  It  can  be 
easily  understood  that  these  last  aneurysms  are  not  recog- 
nized at  the  beginning  of  a  campaign;  this  has  been  pointed 
out  by  Professor  Laurent  of  Brussels.  Sometimes  the 
haematoma  is  tense,  very  painful,  and  infected.  It  might 
be  taken  for  a  vast  phlegmonous  exudation,  which  one 
might  be  tempted  to  incise.  It  is  well  known  that  such 
errors  have  been  committed  by  the  greatest  surgeons. 

After  several  weeks  or  months  of  waiting,  during  which 
time  the  cellular  tissue  of  the  limb  which  has  been  com- 
pressed by  the  blood  has  had  time  to  become  organized,  to 
thicken,  to  form  a  genuine  sac,  we  have  to  deal  more  often 
with  a  localized,  well  circumscribed,  small,  hard  tumour 
which  has  a  souffle  ;  this  constitutes  the  arterial  or  arterio- 
venous aneurysm  ripe  for  operation. 

In  all  cases  the  treatment — that  is  to  say,  the  operation — should 

4 


50  LESIONS  OF  THE  VESSELS 

be  in  the  hands  of  a  skilled  surgeon,  for  it  is  difficult  and 
requires  nerve. 

This  operation  in  primary  diffuse  arterial  haematoma  con- 
sists, after  preliminary  compression  at  some  distance  of  the 
principal  artery,  in  the  free  laying  open  of  the  sac,  search  after 
the  wounded  vessel,  ligature  heloiv  and  above  the  lateral  per- 
foration, or  the  through-and-through  perforation,  and  cross- 
section  of  all  that  remains  of  the  divided  vessel. 

When  the  operation,  instead  of  being  performed  at  once, 
has  been  delayed  for  a  week  or  two,  the  changes  that  have 
taken  place  in  the  sac,  in  its  contents,  or  in  the  neighbouring 
parts,  render  the  search  after  the  artery  more  difficult,  but 
the  method  of  closing  it  is  the  same. 

In  a  completely  circumscribed  aneurysm  recourse  must 
be  had  to  one  of  the  following  plans,  which  at  the  present 
time  are  both  classical :  (i)  Dissecting  out  the  aneurysm  like  a 
tumour  and  removing  it,  after  having  ligatured  the  artery  both 
above  and  below  ;  (2)  opening  the  sac,  and  search  for  the 
artery  in  its  lowest  part.  The  vessel  is  then  tied  with  a 
double  ligature,  and  the  sac  excised  either  partially  or 
completely. 

Extirpation,  which  nowadays  is  the  operation  of  choice, 
gives  favourable  results  in  these  cases.  After  the  Man- 
churian  War,  Bornhaupt  mentioned  fourteen  cases  of  trau- 
matic aneurysm  treated  by  this  method  about  four  weeks 
after  the  wound  had  been  received  ;  a  cure  was  obtained  in 
all  the  fourteen.  Saigo,  after  the  same  campaign,  reported 
fourteen  cases  of  cure  among  fifteen  extirpations  of  arterial 
aneurysms.  The  results  obtained  by  Professor  Laurent  of 
Brussels  are  quite  as  conclusive. 

Arterio- Venous  Aneurysms.  —  Surgeons  have  been 
struck  by  the  relative  frequency  of  arterio-venous  aneu- 
rysms in  recent  wars.  Whilst  during  the  1870-71  war 
only  I  case  in  2,000  wounded  was  noticed,  Hildebrandt 
has  seen  4  cases  in    100  wounds  of  the  vessels.     In  the 


WOUNDS  OF  THE  LARGE  VESSELS         51 

Morocco  campaign  many  wounded  were  treated  in  our 
base  hospitals  for  these  aneurysms  (Rouvillois).  During 
the  present  war  we  should  make  a  point  of  computing  the 
number  of  these  cases,  and  of  elucidating  some  points  in 
their  history  that  are  still  obscure. 

Arterio-venous  aneurysms  occur  after  complete  arterio- 
venous perforation,  after  an  indentation  of  both  the  artery 
and  the  vein  by  a  projectile  that  had  insinuated  itself 
between  them,  or,  finally,  after  a  double  arterio-venous 
contusion,  or  after  a  contusion  of  a  vessel  in  close  proximity 
to  a  traumatic  indentation  in  another. 

These  aneurysms  present  themselves  under  two  principal 
clinical  aspects :  Sometimes  we  see  a  haematoma  which  has 
occurred  at  once  that  is  diffuse,  progressive,  becoming  rapidly 
of  an  enormous  size,  threatening  the  whole  limb  with  rup- 
ture and  gangrene,  very  painful,  easily  recognizable  by  its 
intense  souffle,  whose  thrill  is  carried  for  a  considerable 
distance.  Sometimes  we  see  a  progressive  circumscribed 
tumefaction  of  moderate  size,  which  seems  to  indicate 
expectant  measures  as  much  as  the  first  points  to  imme- 
diate ligature  or  amputation.  Occasionally  we  see  a  tumour 
that  appears  at  a  late  moment  without  any  notable  haemor- 
rhage ;  in  reality  it  is  an  aneurysmal  varix. 

These  different  characteristics  partly  depend  on  the  kind 
of  lesion.  Two  indentations  tend  to  give  rise  to  aneurysmal 
varix  ;  arterio-venous  contusion  to  the  late  tumour  ;  exten- 
sive perforation  and  indentations  to  rapid  tumefaction. 

The  sac  of  an  organized  aneurysm  is  either  on  the  side  of 
the  vessel  or  completely  surrounding  it. 

As  a  general  rule  these  aneurysms  should  be  treated  at 
the  rear  by  a  skilled  surgeon,  as  is  done  with  arterial  aneu- 
rysms whose  condition  is  not  threatening ;  but  when  they 
develop  very  rapidly,  they  necessitate  immediate  ligature  or  a 
more  simple  operation — namely,  amputation.  It  really  seems 
that  on  this  point  there  ought  to  be  no  further  discussion. 


52  LESIONS  OF  THE  VESSELS 

Vital  interests  are  here  concerned,  and  as,  at  the  beginning, 
any  medical  man  may  be  left  in  charge  of  the  case,  he 
must  not  hesitate  to  amputate. 

Under  other  conditions  we  may  employ  conservative 
methods.  Ligature  at  a  distance  has  been  condemned  ;  it  is 
insufficient.  Extirpation  entails  injurious  damage  to  a 
limb,  the  vitality  of  which  is  already  much  impaired.  We 
must  have  recourse  to  incision  of  the  sac  followed  by  ligature 
in  the  sac  of  the  artery  and  the  vein  above  and  below  the 
lesion. 

Suture  can  only  be  successful  in  cases  of  fissure  or  very 
small  indentation  of  the  artery  or  of  the  vein.  If  necessary 
it  may  be  combined  with  ligature  of  the  second  vessel. 

Late  and  Secondary  Haemorrhage.— Laf^  hemorrhage 
generally  comes  on  at  the  end  of  twenty-four  or  forty-eight 
hours  after  either  spontaneous  or  surgically  produced  haemo- 
stasis. 

Cessation  of  syncope,  untimely  movements  on  the  part  of 
the  wounded  man,  or  those  caused  during  the  application 
of  the  dressings,  or  during  the  carrying  out  of  exploration 
whilst  searching  for  splinters  of  bone,  movements  caused 
by  transport,  all  tend  to  displace  the  obturating  clots. 

Late  haemorrhage  is  much  more  rarely  seen  after  wounds 
of  veins  than  after  wounds  of  arteries. 

Secondary  Hcsmorrhage. — It  is  specially  connected  with  a 
septic  condition  of  the  wound.  It  was  very  frequent  in 
former  times,  but  has  become  rare  in  modern  days  ;  but  it 
still  is  seen  (septicaemia,  scurvy,  etc.). 

The  fall  of  the  scab  that  had  formed  on  a  contused 
artery,  ulceration  of  a  vessel  by  a  splinter,  by  a  metallic 
foreign  body,  more  often  disaggregation  of  a  clot  through 
suppuration,  premature  falling  of  a  septic  or  even  of  an 
aseptic  ligature,  may  all  be  causes  of  secondary  haemor- 
rhage. 

We  speak  of  haemorrhage  occurring  from  the  eighth  to 


WOUNDS  OF  THE  LARGE  VESSELS         53 

the  fifteenth  day  as  precocious,  and  of  haemorrhage  appear- 
ing from  the  thirtieth  to  the  fortieth  day  as  late. 

Very  often,  and  especially  when  it  is  connected  with  the 
falling  of  scabs,  the  haemorrhage  is  indicated  by  premonitory 
symptoms  which  the  surgeon  must  not  fail  to  notice  :  rigors, 
vague  pains,  slight  oozing  of  blood,  renewed  and  increasing 
in  quantity  in  proportion  as  the  scab  becomes  more 
separated,  and  staining  the  dressings  a  roseate  hue  (Roux). 

Direct  or  indirect  compression  are  the  first  methods  to 
employ  until  it  is  possible  without  further  delay  to  ligature 
the  two  divided  ends  of  the  vessel.  Such  is  the  treatment  for 
choice.  Putting  a  ligature  on  at  a  distance  would  be  a 
deplorable  mistake. 

Hot  water,  solutions  of  alum,  of  adrenalin,  of  gelatine 
(5  to  10  grammes  of  gelatine  absolutely  sterilized  in  a  litre 
of  normal  saline),  of  antipyrin,  of  antidiphtheritic  serum, 
are  all  useful ;  they  should  be  employed  alone  or  with 
direct  compression  and  in  conjunction  with  ergotine  in 
hypodermic  injections  (fluid  extract  of  the  codex  —  the 
French  Pharmacopoeia — 0*50  in  one  dose,  and  2-50  grammes 
in  the  twenty-four  hours),  white  gelatine  in  hypodermic  in- 
jections (^^^th),  chloride  of  calcium  (4  grammes  every  day 
for  four  or  five  days),  horse  serum  as  a  topic  or  in  hypo- 
dermic injections,  quinine  in  large  doses. 


CHAPTER  V 
WOUNDS  OF  THE  NERVES 

By  reason  of  their  form,  their  mobility,  their  elasticity, 
they  escape  to  a  certain  extent  the  action  of  bullets,  espe- 
cially when  these  last  are  pointed  and  have  only  a  small 
degree  of  velocity.  The  lesions  are  contusion,  partial  abrasion, 
perforation,  total  abrasion. 

1.  Contusions. — We  find  ^ze/o  degrees  of  contusion:  In 
the  first  the  contusion  is  trifling.  The  nerve  does  not 
appear  to  have  suffered  externally  ;  in  its  interior  a  few 
fibres  have  been  destroyed.  In  the  second  degree  the 
external  form  of  the  nerve  has  changed,  it  is  contracted  at 
the  place  where  the  bullet  struck,  above  and  below  it  shows 
a  spindle-shaped  dilatation  caused  by  the  forcing  back  of 
the  myelin.     The  neurilemma  is  separated. 

2.  Partial  Abrasions. — These  are  more  or  less  regular 
indentations  with  forcing  back  of  the  myelin. 

3.  Perforations. — The  bullet  has  pierced  the  centre  of 
the  nerve  in  a  linear  manner,  leaving  the  lateral  portions 
apparently  intact  (Freyer).  The  lesions  are  not  seen 
exclusively  in  the  largest  nerves.  Nerves  of  a  smaller 
calibre — the  median,  the  musculo-spiral,  the  ulnar,  with  a 
diameter  less  than  that  of  the  projectile — are  also  perforated. 

We  do  not  know  the  degree  of  frequency  of  this  curious 
variety  of  traumatism  ;  it  was  not  produced  by  the  old 
bullets,  and  its  frequency  still  has  to  be  determined. 

54 


SIGNS  OF  WOUNDS  OF  NERVES  55 

4.  Abrasions :  Total  Division. — In  these  cases  the 
nerve  shows  a  solution  of  continuity.  Its  extremities  are 
reduced  to  pulp  and  the  myelin  is  forced  back  (bullets, 
shell  splinters). 

Signs  of  Wounds  of  Nerves. — Disturbance  of  feeling, 
of  movement  (paralysis,  cramps,  contractions) ;  disUivhances 
taking  place  at  a  distance  through  reflex  action,  these  may 
show  themselves  immediately  or  a  little  while  after  the 
traumatism ;  they  are  all  too  well  known  for  them  to 
delay  us. 

It  will  be  sufficient  for  us  to  point  out  that  immediate 
pain,  either  localized  or  at  a  distance,  is  rare  (less  than  half 
the  cases),  and  that  immediate  trouble  at  a  distance  must 
be  referred  to  the  hysterical  group  of  disorders. 

Consecutive  disturbances  are  those  of  feeling,  of  motility, 
of  nutrition,  or  they  may  depend  on  a  processus  of  irritation. 

If  the  aseptic  evolution  of  wounds  of  nerves  by  firearms 
takes  place  without  important  phenomena  of  irritation,  in 
cases  of  infection,  of  acute  neuritis,  both  the  localized  and 
the  radiating  pain  is  acute,  tenacious,  intermittent,  or  con- 
tinuous, and  sometimes  accompanied  by  fever,  spasm,  and 
contraction.  The  neuritis,  when  it  becomes  chronic,  may 
assume  the  ascending  form,  and  extend  even  to  the  medullary 
roots  ;  this,  however,  is  less  frequent  than  it  used  to  be. 
In  some  cases  the  pains  bring  on  a  regular  sensorial  tetanus 
(Weir  Mitchell).  Hypersesthesia  is  extreme,  and  is  awakened 
by  the  slightest  contact,  and  in  a  far  greater  degree  at  the 
slightest  fear  of  contact.  Causalgia,  glossiness  of  the  skin, 
and  acute  disturbances  of  nutrition  due  to  neuritis,  are  well 
known  ;  but  let  us  remind  medical  men  that  in  extreme 
cases,  even  well-marked  cerebral  disturbance  has  been 
remarked. 

Although  far  more  rare  nowadays,  thanks  to  the  aseptic 
evolution  of  many  of  the  wounds,  neurotic  phenomena  are 
none  the  less  complications  that  are  to  be  feared  ;  there- 


56  WOUNDS  OF  THE  NERVES 

fore  we  should  strive  to  prevent  them  or  to  Hmit  them  by 
devoting  particular  and  special  care  to  wounds  occurring  in 
the  regions  of  the  large  nerves. 

General  diagnosis  of  wounds  of  the  nerves  by  projectiles 
is  in  most  cases  easy  ;  but,  when  it  is  a  question  of  deter- 
mining the  nature  of  the  lesion,  the  solution  of  the  problem 
becomes  difficult,  often  impossible.  A  great  deal  of  quite 
unjustifiable  interference  is  thus  explained. 

Treatment. — The  treatment,  which  not  long  ago  was 
reduced  to  the  symptomatic  indications,  has  been  enriched 
at  the  end  of  recent  wars  by  improvements  adapted  from 
the  technique  of  everyday  surgery.  In  order  to  appreciate 
their  full  value  we  will  revert  to  what  we  recently  said  on 
the  subject  before  the  Academy  of  Medicine  (February  24, 
1914).- 

This  technique,  we  wish  first  to  point  out,  concerns 
specially  the  work  of  the  surgeons  at  the  rear.  At  the  front 
any  intervention  seems  to  be  contra-indicated,  were  it  only 
on  account  of  the  extreme  difficulties  of  the  diagnosis,  of 
the  complexity  of  a  deceptive  and  excessive  symptomatology, 
which  takes  time  to  be  elucidated  ;  therefore  at  the  front 
we  must  content  ourselves  with  dressing  the  wound  and 
avoiding  all  irritation. 

It  is  all  the  more  indicated  to  make  use  of  this  technique 
at  the  rear,  inasmuch  as  surgery  of  the  nerves  is  not  so 
urgent  with  regard  to  the  time  of  intervention  as  surgery  of 
the  arteries  ;  and  inasmuch  as  in  the  hospitals  at  the  rear 
the  surgeon  can  undertake  these  operations  without  being 
hurried,  at  the  hour  he  chooses,  and  under  the  best  sur- 
rounding conditions.  One  of  the  conditions  for  successful 
operation  in  these  cases  is  very  strict  asepsis. 

We  should  certainly  hesitate  to  put  sutures  into  wounds 

*  Report  on  a  work  by  Professor  Laurent  of  Brussels,  Aneurysms 
and  Wounds  of  Nerves  in  War  Surgery,  O.  C. 


TREATMENT  57 

threatened  with  infection.     It  is  far  preferable  to  wait  for  their 
cicatrization  before  intervening. 

On  the  other  hand,  the  large  nerves  are  nearly  always 
wounded  at  the  same  time  as  the  arteries,  of  which  they 
are  the  satellites  ;  and  the  surgeon  naturally  has  his  attention 
drawn  to  their  injuries  only  at  a  consecutive  period  when 
he  operates  on  the  accompanying  aneurysm,  the  treatment 
of  which  would  plainly  occupy  a  more  important  place 
than  that  of  the  nerve  lesion. 

"  The  lesions  presented  by  nerves  injured  by  projectiles 
are,  we  remarked,  at  the  same  time  less  favourable  for 
successful  operation  and  more  favourable  for  spontaneous 
cicatrization  than  are  wounds  we  see  in  everyday  practice. 
In  these  last  the  nervous  trunks  have  nearly  always  been 
divided  by  an  instrument  or  by  something  sharp ;  they 
have  not  experienced  loss  of  substance,  but,  if  healing  has 
taken  place  with  formation  of  a  neuroma,  its  excision  is  not 
an  addition  to  the  loss  of  substance  resulting  from  the 
primary  traumatism.  This  consideration,  which  up  to  now 
has  not  been  insisted  upon,  should  not  be  lost  sight  of  by 
those  who  wish  to  form  an  appreciation  of  the  indications, 
the  degree  of  usefulness,  and  the  results  of  operative 
interference. 

"  Let  us  discuss  their  expediency,  first  in  cases  of  slight 
contusions.  Although  these  show  originally  sensori-motor 
disturbances  which  might  put  us  on  the  wrong  scent  with 
regard  to  their  real  prognosis,  the  continuity  of  the  nerve  is 
not  interrupted  in  this  instance. 

"In  extensive  contusions  the  nerve  is  deeply  injured  ;  the 
forced-back  myeline  often  gives  rise  to  the  immediate 
formation  of  a  small  neuroma  above  the  point  of  injury. 
Here,  again,  however,  the  continuity  of  the  nerve  is  not 
interrupted.  Why,  then,  should  we  operate  ?  Again,  if 
we  intervene  a  little  time  after  the  traumatism,  to  what 
extent    could    we    carry   the    loss    of    substance    necessi- 


58  WOUNDS  OF  THE  NERVES 

tated  by  the  refreshing  of  the  ends  of  the  nerve  before 
suturing  ? 

"  Amongst  abrasions,  some  are  slight,  and  only  involve  to 
very  small  extent  the  circumference  of  the  nervous  trunk. 
Could  we  but  recognize  them  clinically,  no  one  would  dream 
of  meddling  with  them.  There  are  some,  however,  that  are 
complete  or  nearly  complete,  and  the  forcing  back  of  the  myeline 
is  added  to  the  loss  of  substance.  At  the  period  when  one 
might  think  of  an  operation,  one  must  look  forward  to  having 
to  treat  a  pretty  extensive  loss  of  substance  joined  to  a 
nervous  deterioration,  which  itself  is  rather  large,  and  has 
undefined  limits.  Sutures  might  be  difficult  to  obtain,  and 
their  success  problematical.  These  lesions,  which  are  but 
little  circumscribed,  are  especially  dangerous  when  the  nerve 
has  been  injured  by  a  projectile  having  a  very  great  velocity 
— that  is  to  say,  one  that  has  been  fired  from  a  short 
distance. 

"  In  perforations,  any  immediate  intervention  would  be 
inexplicable.  Freyer,  face  to  face  with  three  wounded  men 
showing  such  lesions,  abstained  from  all  surgical  inter- 
ference. Really,  one  does  not  see  what  other  course  he 
could  have  followed. 

"  It  may  be  gathered  from  these  statements  that  it  seems 
very  difficult  to  recommend  nowadays  any  active  treatment  for 
wounds  of  nerves  by  projectiles  within  a  short  period  from  the 
occurrence  of  the  traumatism,  excepting  in  those  cases  where 
the  nerve  is  pierced  by  a  splinter,  this  having  been  dis- 
covered in  the  course  of  surgical  intervention  for  some 
other  cause. 

"  Putting  aside  such  cases  as  these  last,  we  consider  it 
better  to  allow  Nature  either  to  undertake  repair,  or  to  show 
evidence  of  its  incapacity  to  do  so. 

"  On  the  other  hand,  in  presence  of  this  incapacity,  every- 
thing must  be  tried  to  help  Nature.  Surgical  therapeutics, 
the  results  of  which  have  not  as  yet  been  entirely  satis- 


TREATMENT  59 

factory,  offer  many  methods  for  us  to  utilize,  such  as  dis- 
placement, suUifing  at  a  distance  according  to  Assaky's  plan, 
implantations  J  and  splitting  and  grafting. 

"  A  nerve  compressed  by  a  fibrous  band  or  by  a  callus  in 
the  process  of  formation  should  be  liberated  and  transposed  ; 
partial  excisions  of  neuromata  should  be  done,  followed  by  direct 
suturing ;  total  excisions  of  neuromata,  also  followed  by  direct 
suturing ;  a  splinter  that  has  pierced  a  nerve  should  be 
removed ;  when  there  is  loss  of  substance,  we  should  have 
recourse  to  end-to-end  anastomosis." 

In  order  to  make  a  protecting  canal  for  these  important 
elements  of  repair,  we  can,  following  the  example  of 
Professor  Laurent  of  Brussels,  form  a  sheath  for  the  nerve 
in  a  strip  of  fascia.  This  surgeon  has  chiefly  taken  his 
strips  from  the  extensive  aponeurosis  of  the  fascia  lata. 
From  it  he  detaches,  in  the  form  of  a  graft,  a  square  piece 
of  from  3  to  4  centimetres,  that  he  sutures  by  means  of  silk 
or  catgut  all  round  the  united  ends  of  the  nerve. 

This  way  of  forming  a  sheath  is  only  an  imitation  of  the 
method  of  Van  Lair — the  so-called  tuhulization.  This  sur- 
geon made  each  divided  extremity  of  the  nerve  penetrate  a 
tube  of  decalcified  bone. 

Foratimi(i904)  proposed  making  use  of  arterial  or  venous 
fragments  taken  from  a  freshly  killed  calf;  and  these  pieces 
were  treated  by  immersion  in  formol  and  kept  in  alcohol.'-' 

Two  Japanese  surgeons,  Drs.  Hashimoto  and  Takuoka, 
during  the  Manchurian  War,  made  use  of  the  method  of 
Foratimi,  and  had  nothing  but  praise  for  it.f 

*  Foratimi,  Arch.  /.  Kl.  Chir.,  1904. 

t  Tiie  following  is  the  method  of  preparation  to  which  these  surgeons 
had  recourse  :  Arteries  and  veins  of  different  sizes  are  excised  with  anti- 
septic precautions  from  a  recently  killed  calf ;  they  are  placed  on  a 
glass  stick  ;  after  hardening  in  5  or  10  per  cent,  formol  for  forty-eight 
hours,  they  are  washed  in  running  water  for  thirty  hours,  they  are  then 
boiled  for  twenty  minutes,  and  kept  in  alcohol  at  95°.  Reabsorption 
will  take  place  in  from  two  to  four  months.    The  same  surgeons  have 


6o  WOUNDS  OF  THE  NERVES 

In  the  case  of  one  of  his  men  who  had  a  bayonet  wound, 
and  on  whom  he  had  incised  a  neuroma  of  the  median  nerve, 
Dr.  Laurent  formed  a  sheath  for  the  nerve  from  a  fresh, 
quite  unprepared  piece  of  the  jugular  vein  of  a  sheep.  A 
sheath  made  of  a  graft  was  not  successful. 

The  simple  proposal  made  by  M.  Cuneo  seems  to  have 
been  forgotten :  it  consisted  in  making  use,  for  an  isolating 
tubular  piece,  of  a  portion  of  a  large  superficial  vein  taken 
from  the  patient  himself.  Perhaps  this  is  the  method  of 
the  future.*  We  may  call  it  an  auto-graft.  The  method 
presents  all  the  most  favourable  conditions  for  its  revival, 
it  is  always  ready  to  hand,  and  its  asepsis  is  perfect. 

On  the  whole,  the  questions  dealing  with  the  primary  and 
consecutive  treatment  of  wounds  of  the  nerves  have  not  yet 
had  sufficient  light  thrown  on  them.  The  various  forms  of 
treatment  are  numerous,  but  their  results  have  not  been 
fully  studied.  These  points  are  worthy  of  being  taken  up 
and  completed  during  the  present  campaign. 

In  dealing  with  neuritis  the  surgeon  will  fall  back  on 
sedatives,  on  neurotomy,  and  on  neurotripsy.  We  cannot 
in  such  cases  speak  too  highly  of  powerful,  extreme,  and 
instantaneous  compression  made  by  the  thumb  on  a  level 
with  the  wound  when  the  nerves  are  superficial.  To  this 
species  of  neurotripsy  we  owe  some  remarkable  successes 
in  old  cases  that  had  not  been  ameliorated  by  division  or 
amputation  of  the  nerves,  and  this  in  wounded  soldiers  who 
could  not  possibly  be  suspected  of  hysteria.f 

also  another  way  of  operating,  which  consists  in  displacing  to  a  new 

position  in  the  thickness  of  the  adjoining  muscles  nerves  that  have 

been  sutured.     They  have  obtained  excellent  results. 

♦  Cuneo,  Treatise  by  Le  Dentu  and  Delbet,  article  "Nerves." 

t  Delorme,    "  On   the    Disappearance    of  Neuritic    Symptoms   by 

Localized  and  Forcible  Compression,"  Desportes  Prize.      Journal  de 

Medecine  et  de  Chirurgic  Pratiques,  June  25,  1896. 


CHAPTER  VI 
FOREIGN  BODIES 

Foreign  bodies  which  frequently  cause  complications  in 
gunshot  wounds  are  of  different  nature  :  (i)  The  projectile 
in  its  entirety ;  (2)  objects  torn  off  by  the  projectile  from 
wearing  apparel,  from  articles  of  equipment,  accoutrement, 
or  armament  (buttons,  fragments  of  clothing,  nails,  and 
fragments  of  leather  from  boots) ;  (3)  articles  carried  in  the 
pockets  (spectacles,  coins,  etc.)  ;  (4)  fragments  separated 
by  the  projectile  in  its  flight  or  on  exploding  (earth,  stone, 
or  wood) ;  (5)  fragments  from  the  equipment,  or  even  from 
the  dead  bodies  near  by. 

Of  all  these  various  foreign  bodies,  the  projectile  itself 
and  pieces  of  clothing  are  those  which  are  most  frequently 
found  in  the  wound.  We  find  them  generally  in  cul-de-sac 
wounds,  but  setons  may  also  be  complicated  by  them. 

The  projectile  is  either  whole  or  in  fragments,  in  its 
regular  form,  or  having  lost  its  shape  (contact  with  some 
part  of  the  bones  or  with  the  ground).  Its  changes  of 
shape  and  divisions  must  be  well  understood.  They  differ 
according  to  whether  the  bullet  is  of-  soft  lead,  has  a  pro- 
tective covering,  or  is  in  a  single  piece  of  metal. 

Bullets  of  Soft  Lead. — Bullets  of  soft  lead,  which  are 
still  represented  by  shrapnel  or  case-shot,  spread  out  irregu- 
larly on  touching  the  ground;  they  enter  the  tissues,  but 
not  very  deeply,  making  a  large  opening,  often  more  broad 
than  long.     In  contact  with  the  bones  they  undergo  typical 

61 


62  FOREIGN  BODIES 

changes  of  shape,  which  may  be  spoken  of  as — (i)  Lateral 
changes;  (2)  antero -posterior  changes ;  {^)  division  into  fragments. 

The  first  consist  of  very  regular,  continuous  abrasions, 
which  only  occupy  a  very  small  portion  of  the  diameter  of  the 
bullet. 

The  second  show  the  point  turned  hack,  the  bullet  more  or 
less  flattened  out,  the  flattening  being  sometimes  regularly 
distributed  from  the  centre,  sometimes  deviated  to  one  side. 

In  the  third  case  the  bullet  is  completely  compressed,  flattened, 
and  spread  out  like  a  large  daisy,  the  rear-piece  forming  the 
centre  of  the  flower.  It  is  in  this  extreme  division  into 
fragments  that  the  projectile  is  broken  up  into  very  small 
pieces. 

Bullet  with  a  Protective  Covering. — In  experimental 
firing  at  dead  bodies,  we  have  studied  with  Professor 
Chavasse,  and  we  have  carefully  described  the  changes  in 
shape  of  bullets  with  a  protective  envelope,  of  the  Lebel 
M  bullet,  to  which  the  German  Mauser  bullet  and  also  the 
present  Austrian  Mannlicher  are  analogous.''' 

Although  the  protected  bullet,  when  compared  with  the 
projectiles  of  soft  lead,  is  less  frequently  changed  in  shape 
and  less  frequently  arrested  in  the  tissues,  we  have  noticed — 
and  the  facts  may  still  be  of  importance — 

(a)  That  this  division  into  fragments  was  seen  all  the  move 
readily,  and  that  it  was  all  the  more  complete  the  higher  the  velocity 
of  the  bullet  and  the  greater  the  resistance  of  the  bone  struck. 

(b)  That  bullets,  even  when  fired  from  middle  distances,  were 
arrested  in  the  tissues — a  point  at  that  time  much  contested. 

{c)  That  protected  bullets  caused  divisions  into  fragments 
of  a  special  nature,  this  being  due  to  their  structure. 

The  changes  of  shape  of  these  protected  projectiles  are— 
(i)  At  their  point;  (2)  laterally  ;  (3)  partial  separation  of  the 
protecting  envelope,  with  antero-posteriov  change  of  shape  of  the 

*  E.  Delorme,  Treatise  on  War  Surgery,  vol.  ii.,  p.  96  and  following. 


BULLET  WITH  PROTECTIVE  COVERING     63 

projectile ;  (4)  segmentation,  the  leaden  nucleus  being  completely 
severed  from  its  envelope. 

In  most  cases  these  changes  of  shape  are  isolated  ;  they 
can  be  combined  in  one  and  the  same  bullet, 

I.  Changes  of  Shape  of  the  Point  consist  of  a  cup-like 
depression  of  the  flattened  apex,  or  of  its  surrounding  parts. 
At  a  more  advanced  degree  all  the  conical  part  of  the 
projectile  has  undergone  a  lateral  spreading  out  in  a  more 
or  less  concave  form,  with  rounded  edges ;  generally  there 
are  fissures  in  the  envelope. 

Changes  in  Shape  of  Bullets  that  have  struck  Bones. 


Changes  of  shape  through  contact. 

Fig.  5. — Bullets  of  Soft  Lead. 


Changes  of  shape 
through  perfora- 
tions. 


2.  Lateral  Depressions  are  slight  as  a  rule,  and  may  be 
observed  on  any  point  of  the  cylindrical  surface  of  the 
bullet. 

3.  The  bullet  coming  straight  into  contact  with  a  re- 
sistant body  with  very  considerable  vital  force  is  subjected 
to  a  pressure  which  spreads  out  its  anterior  part ;  the 
envelope  hursts  on  a  level  with  the  flattened-out  extremity. 

Sometimes  the  change  of  shape  consists  of  a  lateral 
bending  over,  either  spiral  or  direct,  with  or  without 
rupture  of  envelope. 

4.  Splitting  into  Fragments  with  Separation  oj  the  Bullefs 


64 


FOREIGN  BODIES 


Nucleus  from  the  Envelope. — Dehiscence  of  the  envelope  facili- 
tates its  separation  from  the  nucleus.  This  separation  is 
either  complete  or  incomplete.  When  it  is  complete,  each 
fragment  follows  a  more  or  less  extended  but  different 
track. 

In  some  cases  splitting  into  fragments  and  separation  are 
regular ;  in  others,  the  envelope  is  subdivided  into  small 
scales,  distorted  with  cutting  edges.  The  nucleus  crumbles 
into  dust  or  into  small  fragments.  The  whole  mass  has 
been  projected  in  a  shower  and  has  exploded.     Even  in 


■S"^      \ 


t£sJ 


Changes  of  shape 
through  contact. 


Changes  of  shape 
through  perforations. 


Separation  of  the  nucleus 
from  the  envelope. 


Fig,  6. — Bullets  with  Envelope. 


these  extreme  cases  the  nucleus  is  represented  by  a  frag- 
ment larger  than  the  others.  It  would  be  folly  to  search 
for  such  fragments,  the  whole  limb  would  have  to  be  cut 
into,  and  even  then  they  would  not  be  found.  These 
divergent  seed-like  fragments  are  well  shown  by  radio- 
graphy. 

These  changes  of  shape  and  large  segments  occur 
through  contact  with  the  diaphyses,  but  they  are  also  seen 
when  the  bullet  has  touched  hard  ground  before  reaching 
the  body.  The  bullet  now  becomes  a  foreign  body,  con- 
sisting of  one  or  many  irregular  fragments  of  the  envelope 
or  of  the  nucleus. 

During  the  Cuban  War  awful  traumatisms  were  caused 
by  very  much  broken  up  and  ricochetted  bullets.     During 


BULLET  D  65 

a  riot  in  St;  Petefsburg,  when  the  order  was  given,  with 
a  humanitarian  purpose  in  view,  to  aim  at  the  ground  when 
firing,  wounds  of  an  exceptionally  serious  character  were 
caused  by  the  bullets  which  had  ricochetted  from  the  paved 
road.     We  saw  the  same  thing  happen  at  Fourmies. 

This  dividing  into  fragments  is  brought  about  by  the 
active  force  of  the  bullet  that  has  an  envelope.  With  a  very 
high  velocity,  the  struggle  between  power  and  resistance  is 
at  the  same  time  so  instantaneous  and  so  intense,  that  in 
most  cases  the  bullet  is  subdivided  into  very  small  frag- 
ments. On  the  contrary,  with  less  velocity  it  passes  through 
the  diaphyses  without  notable  change  of  shape,  or  even 
without  any  change  of  shape  whatever. 

Bullet  D. — The  changes  of  shape  the  D  bullet,  which, 
as  we  know,  is  formed  of  a  single  piece  of  brass,  undergoes 
when  in  contact  with  the  soil  in  ricochetting,  in  striking 
against  metallic  parts  of  the  soldier's  equipment,  or  against 
hard  parts  of  the  human  body  (bones),  are  far  less  frequent 
and  not  nearly  so  pronounced  as  those  of  other  bullets. 
Bullets  changed  in  shape  through  contact  with  stony  ground 
retain  but  little  penetrating  power,  and  after  having  pierced 
the  tissues  by  a  large  aperture,  they  remain  at  a  short 
distance  from  the  skin. 

Average  changes  of  shape  consist  generally  of  a  turning 
up  of  the  point,  which  becomes  more  or  less  curved,  some- 
times bent  at  right  angles.  The  changes  of  shape  of  the 
base  show  flattening  or  incurvation,  those  of  the  body 
inflection. 

Slight  changes  of  shape  are  of  the  same  nature,  but  not 
so  pronounced.  Prominent  and  considerable  changes  of 
shape  are  rarely  observed  when  bones  are  struck  by  the 
bullet.  After  striking  against  very  resistant  obstacles,  such 
as  certain  kinds  of  stone,  gun-shields,  or  iron  plating,  bullets 
may  be  flattened  out  into  the  form  of  a  daisy  and  become 
subdivided ;  this,  however,  is  rare.     Finally,  the  D  bullet 

5 


66  FOREIGN  BODIES 

has  its  shape  altered  rather  on  striking  against  external 
obstacles  than  against  the  bones ;  when  it  encounters  the 
latter  the  alteration  in  shape  is  but  slight. 

Bullets  from  Shrapnel. — These  bullets  of  hardened  lead, 
formed  of  two  parts  joined  together,  are  frequently  broken 
into  two  symmetrical  halves.  They  undergo  similar  changes 
of  shape  to  those  seen  in  soft-lead  bullets  (lateral,  antero- 
posterior alterations  of  shape,  deformation,  segmentation). 
It  must  not  be  forgotten  that  the  flat  facets  they  show  are 
due  to  their  collisions  against  neighbouring  bullets  at  the 
moment  of  the  shell's  explosion. 

Fragments  of  Clothing  are  typified  either  by  conglomer- 
ate large  pieces  of  material  or  of  many  very  small  bits.  The 
conglomeration  is  made  up  of  superposed,  united  pieces  in 
layers  of  the  soldier's  tunic,  flannel  band,  shirt,  trousers 
and  drawers,  the  number  of  pieces  being  much  increased 
when  the  clothing  happens  to  be  in  folds.  The  diametrical 
dimensions  of  the  conglomeration  are  a  little  less  than  the 
bullet's  surface  of  impaction.  The  projectile  produces 
abrasion,  especially  when  its  active  power  is  sufficiently 
great  to  enable  it  to  act  mechanically  as  a  punch. 

This  conglomeration  of  pieces  of  clothing,  which  is  fre- 
quently observed  with  soft-lead  bullets,  and  with  bullets 
having  a  defensive  envelope  and  a  flattened  apex,  is  not 
found  in  wounds  made  by  conical  bullets  fired  point-blank. 
On  the  contrary,  they  are  met  with  in  wounds  due  to 
deflected  bullets,  and  usually  in  wounds  from  shrapnel  and 
from  shell  splinters. 

In  our  experiments  on  dead  bodies  with  the  Gras  and 
Lebel  bullets,  we  were  somewhat  surprised  to  find  that  in 
most  cases  the  greater  part  of  the  track  of  the  bullet  was 
lined  with  thin  filaments  of  wool  emanating  from  the  trousers 
and  the  overcoat,  easily  recognized  by  their  colour.*  The 
presence  in  the  wound  of  these  very  infinitesimal  pieces 
*  E.  Delorme,  Treatise  on  War  Surgery,  vol.  i.,  p.  553. 


FRAGMENTS  OF  CLOTHING  67 

has  been  confirmed  by  all  those  who  have  carried  out 
similar  experiments.  Reverdin  says  that,  as  a  result  of  his 
experiments,  a  wound  made  through  a  cloth  uniform  by 
bullets  having  a  protecting  envelope  is,  nearly  without 
exception,  complicated  by  the  presence  of  very  small  debris, 
especially  just  under  the  skin  at  the  aperture  of  entry. 

As  we  have  often  pointed  out,  the  bullet,  when  it  comes 
in  contact  with  unyielding  fasciae,  the  fibres  of  which  in 
most  cases  it  simply  thrusts  aside,  gets  rid  of  the  fragments 
it  has  carried  along.  The  latter  are  not  only  found  near  the 
aperture  of  entry  in  the  subjacent  enveloping  fasciae,  but 
also  in  other  parts  of  the  track,  even  in  Pirogoff 's  pouch — 
that  is  to  say,  between  the  separated  skin  and  the  last  layer 
of  aponeurosis  traversed  by  the  bullet  before  reaching  the 
aperture  of  exit  (Reverdin). 

An  interesting  fact  is  the  pro}ection  of  these  filaments  into 
the  thickness  of  the  tissues  all  arotind  the  track  at  distances  we 
are  far  from  suspecting,  sometimes  attaining  several  centimetres. 

The  question  dealing  with  the  lodgment  of  fragments 
of  clothing  in  wounds  is  too  intimately  connected  with  the 
evolution  of  the  traumatism  for  us  to  neglect  its  present 
study ;  at  this  point  we  can  say  that  it  is  specially  im- 
portant to  recognize  the  presence  of  these  conglomerations 
of  detached  clothing.  Now,  if  diagnosis  of  metallic  foreign 
bodies  is  easy,  thanks  to  the  methods  of  exploration  now  in 
use,  that  of  particles  of  clothing  seems  impossible,  as  there 
is  nothing  to  indicate  their  presence  in  the  midst  of  the 
tissues.  Such,  indeed,  would  be  the  case  were  there  not  an 
unfailing  means  of  ascertaining  their  presence,  and  that  is 
by  direct  examination  of  the  clothes  themselves.  With 
reference  to  this  question  we  will  formulate  the  following 
data : 

I.  Examination  of  the  clothes ^  often  impossible,  besides  being 
useless,  at  the  front,  is  absolutely  necessary  when  the  wounded  man 
has  been  removed  to  the  rear. 


68  FOREIGN  BODIES 

2.  At  the  front  we  should  be  careful  not  to  sacrifice  clothing 
through  which  a  hdlet  has  penetrated  by  cutting  it  where  it  has 
been  perforated.  A  t  the  rear  one  should  be  careful  not  to  deprive 
the  wounded  man  of  his  garments^  nor  to  wash  them,  as  this 
would  alter  their  aspect.  A  soiled  and  torn  uniform  must 
not  be  looked  upon  as  rags,  but  rather  as  a  trophy ;  more- 
over, it  is  a  valuable  component  part  of  a  most  useful 
diagnosis,  which  may  have  to  be  renewed  by  the  different 
surgeons  who,  in  succession,  may  have  the  wounded  under 
their  charge. 

3.  When,  after  the  edges  of  the  apertures  have  been 
carefully  drawn  together,  we  find,  in  spite  of  the  primary 
;and  delusive  gaping,  that  there  is  no  notable  loss  of  substance, 
we  may  affirm  that  the  wound  is  free  from  a  conglomeration  of 
pieces  of  clothing."^ 

4.  Not  only  one,  but  every  piece  of  the  wounded  man's  clothing 
should  be  examined,  as  well  as  the  linings,  for  linen,  being  less 
elastic  than  cloth,  its  fragments  are  frequently  more  notice- 
able than  those  of  the  latter ;  they  may  even  be  present  as 
isolated  foreign  bodies. 

Diagnosis.  —  A  single  wound,  hard  and  painful  swelling, 
localized  pain  at  some  distance  from  the  aperture  of  entry, 
even  in  the  case  of  setons,  are  indicative  of  the  presence  of 
metallic  foreign  bodies. 

The  numerous  methods  of  exploration  and  diagnosis  that 
authors  formerly  dwelt  on  with  such  complacency,  from 
the  metallic  probe  to  the  electric  exploring  apparatus,  have 
now  only  an  historical  value. 

All  these  methods  are  now  superseded  by  radiography, 
and   not   only   does    radiography   allow   us  to    attest   the 

*  Although  in  theory  it  is  not  important  to  examine  the  aperture  of 
exit  through  which  the  pieces  of  clothing  might  have  emerged,  as  they 
have  already  been  expelled  by  the  bullet,  nevertheless  we  advise  an 
examination  of  both  apertures,  because  it  is  not  always  possible  to 
diagnose  one  from  the  other. 


TREATMENT  69 

presence  of  foreign  bodies,  yet  it  is  perhaps  going  too  far 
to  say  that  it  shows  us  precisely  the  place  where  they  are 
located. 

Wounds  in  which  foreign  bodies  are  thought  to  be  lodged 
should  be  examined  in  the  rear  by  radiography,  not  by  radi- 
oscopy. If  the  ambulance  is  not  provided  with  apparatus, 
the  wounded  men  should  be  taken  to  the  nearest  hospital 
to  undergo  an  examination,  after  which  they  must  be  sent 
back  to  the  point  from  which  they  started.  Each  patient 
is  entitled  to  one  examination.  It  gives  the  origin  of  the 
mischief. 

Treatment. — The  question  as  to  the  expediency  of  extracting 
metallic  foreign  bodies  is  one  that  has  been  greatly  discussed. 
Those  lodged  in  the  soft  tissues  are  generally  very  well 
tolerated.  It  is  well  known  nowadays  that  in  this  toler- 
ance their  own  characteristics,  their  nature,  their  form, 
their  size,  are  not  of  nearly  so  much  importance  as  asepsis 
of  the  wound. 

In  a  septic  or  suppurating  umind  a  metallic  foreign  body  is  not 
tolerated.  Therefore  at  present,  by  common  consent,  it  is 
admitted  that — 

1.  A  metallic  foreign  body,  which  is  tolerated,  causing  neither 
uneasiness  nor  pain,  should  be  left  alone. 

2.  A  foreign  body  that  gives  rise  to  pain,  is  badly  tolerated, 
that  causes  uneasiness  by  coming  into  contact  with  vessels  or  nerves, 
or  that  is  situated  in  a  focus  of  suppuration,  must  be  removed. 

3.  A  bullet  that  is  almost  level  with  the  skin  may  be  removed 
to  gratify  the  patient,  provided  that  the  incision  does  not  open  a 
cavity,  and  provided  also  the  ablation  be  done  in  a  permanent 
shelter  where  all  the  usual  precautions  can  be  taken. 

Another  reason  which  militates  in  favour  of  this  last 
condition  is  that  certain  foreign  bodies,  which  seem  to  be 
superficial  and  easy  of  extraction  in  the  light  of  radi- 
ography, give  rise  in  many  cases  to  difficulties  that  protract 
the  operation. 


70  FOREIGN  BODIES 

4.  A  shell  fragment  that  is  large,  irregtdar,  and  sharp,  and 
also  a  shrapnel  bullet,  must  ki^^kys  he  removed  shortly  after  the 
traumatism  ;  this  should  he  done  in  a  permanent  shelter  either  at 
the  front  or  in  the  rear. 

5.  Ablation  of  these  last  foreign  metallic  bodies  is  speci- 
ally necessary,  because  they  close  the  cul-de-sac  in  which  are 
lodged  infecting  foreign  bodies  derived  from  the  clothes, 
and  because  ablation  of  the  metallic  body  is  the  best  way 
of  setting  free  fragments  of  wearing  apparel. 

6.  Removal  of  these  last  metallic  bodies  should  be 
carried  out  very  shortly  after  the  traumatism,  either 
immediately  or  a  few  days  after. 

Special  instruments  are  not  necessary  for  the  extraction 
of  metallic  foreign  bodies.  At  the  bottom  of  the  exploratory 
incision,  which  must  be  methodically  carried  out,  great  care 
being  taken  not  to  injure  important  organs,  a  pair  of 
dressing  or  forcipressure  forceps,  guided  by  the  surgeon's 
left  forefinger,  will  suffice  for  their  gentle  extraction. 


CHAPTER  VII 
BONY  LESIONS  OF  THE  DIAPHYSES 

There  is  no  traumatism  that  brings  into  such  strong 
relief  the  striking  differences  separating  war  surgery  from 
ordinary  surgery  as  the  bony  lesions  of  the  diaphyses.  A 
surgeon  who  considers  he  can  base  their  treatment  on  his 
general  ideas  would  be  liable,  unfortunately  for  the  wounded, 
to  remain  very  inferior  to  the  ideal  of  the  duty  he  has 
undertaken. 

The  adoption  of  the  new  projectiles  has  brought  with  it 
no  important  modification  in  the  data  derived  from  experi- 
ments on  the  dead  body,  on  the  one  hand,  and  from  experi- 
ence acquired  in  recent  wars  on  the  other. 

According  to  world-wide  statistics,  lesions  of  the  bones 
are  seen  during  a  campaign  in  a  proportion  of  one-fifth  of 
all  wounds. 

Cold-steel  weapons  lead  to  sections  of  the  diaphyses ;  pro- 
jectiles to  contusions,  cracks,  and  fissures^  to  fractures  by  contact, 
perforation  of  one  side  of  the  bone,  perforation  right  throtcgh,  and 
to  grooves. 

This  classification  should  be  adopted  by  all  surgeons,  in 
the  first  place  because  it  is  based  on  strictly  exact  and  con- 
stant provisions,  in  the  second  place  because  it  originates 
from  our  chief  practical  data. 

Lesions  caused  by  Projectiles. 
Contusions. — These  are  either  the  result  of  direct  shock 
or  of  tangential  contact  of  the  projectiles.     They  are  very 

71 


72 


BONY  LESIONS  OF  THE  DIAPHYSES 


frequently  produced  by  bullets,  but  are  often  unperceived 
on  account  of  their  giving  rise  to  no  immediate  signs. 

At  the  seat  of  the  contusion  the  periosteum  is  involved 
and  destroyed,  and  the  marrow  may  or  may  not  show  either 
circumscribed  or  extensive  pouring  oat  of  blood. 

Cracks  and  Fissures. — Isolated  cracks  and  fissures  of 
the  diaphyses  are  also  frequent,  but,  like  bony  contusions, 
they  nearly  always  are  unperceived.     Wounded  men  who 


5./. 


oj. 


.^t-h- 


-gx 


■V. 


Fig.  7. 

s./.,  Symmetrical  fissure  (direct  contact) ;  0/.,  opposite  fissure  (tangential 
contact) ;  d.c,  direct  contact ;  t.c,  tangential  contact. 

present  long  fissures  of  the  bones  of  the  lower  limbs  can 
walk  when  left  to  themselves. 

A  cvach  is  a  cleft  whose  sides  are  very  near  together,  and 
can  hardly  be  seen ;  a  fissure  is  a  visible  cleft  whose  sides  are 
widely  separated. 

The  most  remarkable  are  the  longitudinal  cracks  and 
fissures,  often  very  extensive ;  they  are  either  single  or 
multiple,  but  some  are  oblique,  some  curved.  Isolated  cracks 
and  Jissuves  are  outlines  of  those  that  fix  the  limits  of  fractures 
by  contact,  of  which  they  show  the  direction  and  position 
(Delorme). 

Symmetrical  fissure  and  opposite  fissure  are  the  most  striking 


LESIONS  CAUSED  BY  PROJECTILES         73 


and  the  most  constant  lesions  of  the  diaphyses.  The  former 
furrows  the  side  of  the  bone  that  has  not  been  hit,  and  this 
happens  in  the  plane  passing  through  the  point  of  contact  of  the 
projectile.  It  is  the  result  of  direct  contact  of  the  bullet  (s/.) 
Opposite  fissure  is  also  seen  on  the  side  of  the  bone  that  has 
not  been  hit,  but  this  fissure  is  found  on  a  perpendicular 
plane  to  the  track  of  the  projectile.  It  is  the  result  of  a  tangential 
contact  {of.). 

These  fissures  are  seen  on  all  the  long  bones.     Absolute 
diagnosis  up  to  now  has  been  very  difficult,  for  neither  in 


Direct. 


Indirect. 


'^fi^^>^^ 


P^ 


<r::T^^ 


Fig.  8.— Contact  Fractures  (Transverse  and  Oblique). 

bone  contusions  or  in  fissures  was  there  anything  charac- 
teristic with  regard  to  shock,  inability  to  use  the  limb,  denudation 
of  the  bone,  deviation  in  the  course  of  the  projectile,  its  change  of 
shape  if  it  remained  in  the  limb,  increase  in  size  of  the  aperture 
of  exit,  relationship  of  the  track  to  the  bone. 

Radiography  sometimes  affords  a  certain  diagnosis,  but 
this  is  not  constant. 

Fractures  by  Contact.— These  are  the  result  of  the 
direct  or  indirect  (tangential)  contact  of  a  bullet  fired  point- 
blank,  or  that  has  ricochetted  or  been  deflected. 

We  recognize  fra.ctures  by  contact  as  transverse,  obliqtte—^ 


74 


BONY  LESIONS  OF  THE  DIAPHYSES 


that  is  to  say,  forming  a  simple  line  of  fracture ;  and 
fractures  that  have  large  splinters  of  bone. 

Transverse  and  Oblique  Fractures. — Relying  on  our 
experience,  we  have  asserted  that  transverse  and  oblique 
fractures  are  not  very  rare.  The  teachings  of  the  Trans- 
vaal War  have  confirmed  our  dictum,  and  the  present  war 
strengthens  it  still  more. 

Sometimes  the  fracture  corresponds  exactly  to  the  point 


ist  Type. 


2nd  Type. 


3rd  Type.  4th  Type. 


5th  Type. 


s./. 


5./. 


s.f. 


s.f. 


s.f. 


Fig.  9. — Contact  Fractures  with  Large  Splinters  (no  Com- 
minution). 


of  the  bone  hit  by  the  bullet  [direct  fracture),  sometimes  it 
occurs  at  2,  3,  10  centimetres  from  the  place  of  the  bullet's 
contact  (indirect  fracture).  Indirect  fracture  can  be  single  or 
double,  and  its  line  can  either  be  simple  or  accompanied  by 
longitudinal  fissures. 

Fractures  with  Large  Splinters. — In  these  fractures, 
which  are  well  known  ever  since  we  fully  described  them, 
the  lesions  extend  more  in  the  direction  of  the  axis  of  the 
bone  than  perpendicularly  to  it. 


LESIONS  CA  USED  BY  PROJECTILES  75 

Five  ^  different  types  will  be  found  in  ttie  illustration  on 

P-  74- 

First  Type  :    This   is   the  most   important.      From  the 

point  of  impact  extend  four  diverging  curvilinear  fissures, 

the  convexity  of  which  is  turned  towards  the  axis  of  the 

diaphysis  ;    these  fissures  are  united  on  the  side  of  bone 

which   is   not    hit   to   the   large   symmetrical   longitudinal 

fissure  (5./.).     These  fissures  enclose  two  large  triangular 

splinters  facing  one  another  at  their  apex ;  they  are  placed 

between  the  superior  and  inferior  fragments  ;  their  pointed 

extremities  have  undergone  no  loss  of  substance.     This  is  a  point 

to  remember. 

These  splinters  may  occupy  a  quarter,  a  third,  or  one- 
half  of  the  bone. 

At  the  point  of  contact  the  periosteum  is  destroyed,  the 
bone  contused ;  all  along  the  fissures  it  is  raised  by  blood 
and  marrow  reduced  to  pulp ;  suffusion  of  blood  is  seen  in 
the  medulla. 

Second  Type :  This  is  a  fracture  with  large  splinters  sub- 
divided transversely  ov  obliquely  at  their  centre.     (Rare.) 

Third  Type  :  Oblique  longitudinal  spiroid  fracture.  On  the 
side  of  the  bone  corresponding  to  the  point  of  contact  there 
is  a  very  oblique  line  in  the  form  of  an  elongated  S,  which 
by  its  curved  extremities  joins  the  longitudinal  symmetrical 
fissure.  This  exceptional  type  is  almost  exclusively  seen 
in  the  femur  (upper  third). 

Fourth  Type :  Fracture  having  the  shape  of  ay ,  cuneiform  ^ 
and  with  one  large  splinter.  It  is  the  fracture  of  the  first  type,  or 
in  the  form  of  an  X,  in  which  the  line  of  one  of  the  splinters 
is  wanting.  Of  the  two  fragments  one  has  the  shape  of  a 
V,  or  of  a  wedge,  and  is  sometimes  above,  sometimes  below  ; 
the  other  takes  the  form  of  a  radish.  This  fracture  is 
frequent. 

Fifth  Type :  Fracture  with  one  splinter,  and  transverse  sub- 
division of  the  remainder  of  the  bone,     (Rare.) 


76 


BONY  LESIONS  OF  THE  DIAPHYSES 


Such  are  the  simple  types,  without  comminution,  that  are 
produced  on  the  diaphyses  by  contact  with  bullets.  The 
bone  is  fissured  or  broken  ;  the  fragments,  whose  limits  are 
marked,  are  either  held  closely  together  by  their  serrated 
edges  (in  which  case  the  continuity  of  the  limb  will  not  be 
interfered  with  so  long  as  the  bone  is  not  subjected  to  any 
shock  or  to  untimely  exploration),  or  else  the  fragments  and 
the  splinters  are  from  the  very  beginning  separated  as  in  an 
ordinary  fracture. 

At  all  events,  the  hone  has  not  suffered,  either  in  its  splinters  or 
in  its  fragments,  any  loss  of  substance,  and  the  periosteum  is  still 


s.f.- 


FiG.  lo. — Contact  Fractures,  with  Large  Splinters  and 

Comminution. 

adherent.     All  these  conditions  are  favourable  to  a  simple 
and  rapid  cure. 

If  the  projectile,  producing  the  fracture  by  contact,  has 
very  great  active  force,  it  will  give  rise  to  fractures  by 
contact  with  comminution.  On  the  whole,  these  fractures  are 
limited  by  large  fissures  whose  direction  is  characteristic ; 
but  the  large  splinters,  instead  of  being  intact,  are  sub- 
divided in  one  place,  more  rarely  in  two  or  three,  by  large 
fissural  tracts,  parallel  to  those  that  mark  the  limits  of  these 
principal  splinters,  sometimes  by  more  or  less  vertical  tracts, 
pr  by  others  that  are  perpendicular  or  oblique. 


LESIONS  CA  USED  BY  PROJECTILES         77 

The  periosteum,  which  has  become  separated  from  the 
bone,  is  raised  to  the  level  of  each  secondary  fissural  tract ; 
but  whether  the  subdivided  splinters  remain  in  situ  or  are 
displaced  by  the  faulty  position  of  the  superior  or  inferior 
fragments,  the  comminuted  fracture  by  contact  retains  its 
main  characteristics :  the  extremity  of  its  fragments  is  sharp, 

WITHOUT  LOSS  OF  SUBSTANCE  ;    THERE  IS  NO  FREE  SPLINTER  ; 

all  the  splinters  are  adherent. 

The  conditions  governing  the  manner  of  arrangement  of 
fractures  by  contact  with  large  splinters  give  the  keynote 
to  lesions  connected  with  perforations  or  grooves,  for,  as  we 
have  proved,  a  perforation  or  a  groove  is  hut  a  fracture  by  con- 
tact with  a  perforation  or  a  groove  superadded. 

Perforations. — By  experiments  we  have  proved  that 
fracture  caused  by  perforation,  whether  with  or  without 
comminution,  is  the  habitual  form  of  fracture  produced  by 
firearms. 

We  have  recognized  two  kinds  which  have  been  generally 
accepted  :  Incomplete  perforations — that  is  to  say,  perforation  oj 
only  one  side  of  the  hone,  and  complete  perforations,  when  both 
sides  of  the  diaphysis  are  involved. 

Incomplete  Perforations.  —  Incomplete  perforation  —  that 
is  to  say,  of  only  one  side  of  the  bone — can  only  be 
produced  (and  this  is  easily  understood)  by  bullets  whose 
velocity  cannot  he  very  great,  since  they  have  not  been  able  to 
continue  their  course.  Therefore,  as  comminution  of  a 
fracture  is  in  inverse  ratio  to  the  extent  of  motion  acquired 
by  the  bullet,  it  is  evident  that  these  fractures  must  always  he 
simple  in  type.  On  the  other  hand,  however,  we  must  not 
forget  that  the  bullet  has  not  only  made  a  perforation  in  the 
diaphysis,  but  that,  by  its  simple  contact,  before  causing  the 
perforation,  it  has  given  rise  to  the  longitudinal  fissures  seen 
in  fractures  by  contact. 

It  is  the  first  X  type  oi  fractures  hy  contact  that  is  connected 
with  perforation  of  only  one  side  of  the  hone.     With  the  fissures 


78 


BONY  LESIONS  OF  THE  DIAPHYSES 


and  the  large  splinters,  which  we  need  not  describe  again, 
there  is  an  orifice  in  the  bone,  generally  rounded  in  shape, 
sometimes  oval,  whose  diametrical  dimensions  are  less  than 
those  of  the  bullet.  The  latter  may  be  in  the  medullary 
canal  at  the  level  of  its  aperture  of  entry ;  occasionally 
it  has  slipped  down  the  canal,  or  it  may  have  come  into 
contact  with  the  inside  of  the  opposite  wall  of  the  bone, 


/ 


e^x- 


S. ;.  .- 


a.e. 


s.f. 


I 


Apertures  of  Entry.  Apertures  of  Exit. 

Fig.   II. — Fractures  with  Complete  Perforation. 


Focus  Swept 
Away. 


giving  rise  to  some  short  splinters,  but  as  it  has  not  sufficient 
strength  left  to  emerge,  it  remains  where  it  is. 

Complete  Perforations, — The  projectile  that  produces 
them  having  a  sufficient  but  variable  active  power  to  go 
through  the  two  bony  walls,  complete  perforations  are 
either  more  or  less  simple,  or  else  commimited,  even  excessively 
comminuted. 

In   regard  to  the  general  direction  of  the  fissures,  the 


LESIONS  CA  USED  BY  PROJECTILES  79 

limitation  of  the  splinters,  and  the  shape  of  the  fragments, 
fracture  by  complete  perforation  nearly  always  shows  much  re- 
semblance to  fracture  by  contact  with  two  more  or  less  subdivided 
large  lateral  splinters^  or  to  cuneiform  \/ -shaped  fractures  (Fig.  11, 
I  and  2). 

The  bony  aperture  of  entry  is  circular  and  regular,  of  the 
same  dimensions  as  the  projectile,  or  smaller,  occasionally 
oval  in  shape. 

The  bony  aperture  of  exit  is  variable  in  form.      Rarely 


( 


Fig.  12. — Fractures  by  Grooves. 

I.  Groove  of  ridge.  2.  Groove  of  ridge  w^ith  oblique  fracture.  3.  Groove 
with  one  or  tv^'o  large  lateral  splinters.  4.  Shows  the  breach  made  by  the 
bullet  in  a  subdivision  of  the  large  splinter. 

circular  and  regular,  it  is  nearly  always,  owing  to  loss  of  sub- 
stance, more  or  less  quadrilateral,  its  borders  being  formed 
by  the  splinters  that  the  projectile  has  detached  (Fig.  ii, 
3  and  4).  These  splinters,  more  or  less  free,  are  then 
stationary ;  they  can,  however,  be  thrown  off. 

In  such  an  instance  the  bullet  has  not  acted  alone,  as 
in  a  contact  fracture  or  in  perforation  of  only  one  bony  wall. 
The  splinters  it  has  torn  off  at  the  aperture  of  entry,  the 
subdivided  splinters  close  to  the  track  to  which  the  bullet 


8o        BONY  LESIONS  OF  THE  DIAPHYSES 

has  communicated  part  of  its  active  power,  the  fragments 
of  the  bullet  which  may  have  broken  in  pieces,  have  all 
acted  as  secondary  projectiles.  These  last,  propelled  towards 
the  bony  aperture  of  exit  in  a  more  or  less  irregular  manner, 
have  increased  the  damage,  and  have  given  rise  in  some 
cases  to  a  fracture  feelmg  like  a  hag  of  nuts  ;  even  in  some 
instances  the  seat  of  fracture  has  been  freed  from  splinters 
(focus  swept  away  J  bullet  fired  from  a  very  short  distance — 

Fig.  II,  5)' 

Grooves. — In  frequency  they  come  after  perforations. 

They  are  more  or  less  deep  furrows  in  which  one  might 
accommodate  a  quarter,  a  half,  even  three-quarters  of  the 
diameter  of  the  bullet ;  if  deeper,  the  groove  would  become 
a  perforation. 

Grooves  generally  affect  but  a  very  small  extent  the 
transverse  diameter  of  the  bone.  We  must  differentiate 
the  grooves  of  the  ridges  from  those  of  the  body  of  the 
diaphyses. 

Grooves  of  the  Sides  and  of  the  Ridges  of  the  Bone. — When 
the  anterior  ridge  of  the  tibia,  the  sides  of  the  same  bone, 
the  edges  of  the  inferior  extremity  of  the  humerus,  the 
linea  aspera,  the  sharp  edges  of  the  radius  or  of  the  ulna, 
are  indented,  the  indentation  is  sometimes  distinct  and 
isolated,  sometimes  it  is  accompanied  by  a  transverse  or 
an  oblique  fracture  (Fig.  12). 

Grooves  on  the  Body  of  the  Diaphyses. — They  have  a  close 
relationship  to  the  types  of  contact  fractures  we  have 
described,  especially  to  the  first  and  the  fourth  (type  with 
large  splinters,  the  cuneiform  V-shaped  type). 

As  the  bone,  in  the  tangential  contact  that  precedes  the 
abrasion  causing  a  groove,  cannot  have  received  a  shock 
from  active  force  as  intense  as  the  one  it  would  experience 
when  struck  point-blank,  which  would  lead  to  perforation, 
the  groove  may  generally  be  placed  in  the  type  in  which  there  is 
little  or  but  slight  comminution.     This  is  an  important  fact. 


LESIONS  CAUSED  BY  PROJECTILES        8i 

It  tesults  from  this  that  a  great  many  grooves  exist 
without  any  solution  of  continuity  of  the  bone.  Undoubt- 
edly we  may  see  rather  shallow  grooves  of  the  diaphyses 
which  consist  of  abrasions  without  fissures,  but  this  is 
exceptional,  and  usually  a  fracture  by  contact  accompanies 
the  grooving  of  the  bone. 

When  the  bullet  has  bored  in  the  body  of  the  bone  a 
rather  deep  track,  it  has  not  only  indicated  the  limits  of 
one  or  two  large  splinters,  the  lines  of  whose  fissures  join 
the  big  fissure  of  the  wall  perpendicular  to  the  track  of 
the  bullet  (opposite  fissure)^  but  also  it  has  brought  about, 
symmetrically  at  its  pointy  a  short  symmetrical  longitudinal 
Assure,  and  in  the  centre  of  this  subdivision  of  splinters,  in 
the  centre  of  this  secondary  splinter,  which  to  all  intents 
and  purposes  is  adherent,  the  bullet  has  travelled,  piercing 
a  narrow  track  in  its  passage. 

In  complete  perforations  the  shape  of  the  bullet  is 
altered  ;  it  subdivides  if  it  is  provided  with  a  covering.  As 
we  have  before  pointed  out,  it  changes  many  of  the  splinters 
into  secondary  projectiles,  which  increase  in  number,  and 
hy  their  commimition  extend  the  field  of  damage.  In  such  a 
case  there  is  no  change  of  shape  of  the  bullet,  the  reduction 
of  the  splinters  into  fragments  is  shown  by  their  transforma- 
tion into  dust,  which  is  gently  projected  into  the  soft  parts. 

Fracture  by  groove  can  be  distinguished  from  the  multi- 
plicity of  fractures  through  perforation  by  its  invariable 
simplicity. 

Splinters  are  pieces  of  bone  whose  limits  depend  on  the 
projectile  ;  they  are  connected  with  the  foci  of  the  fractures, 
and  may  be  divided  into  free  and  adherent. 

I.  Free  Splinters. — The  smallest  of  these  may  only  be 
represented  by  a  kind  of  glazed  bone-dust,  resulting  from 
the  first  hard,  bony  layer  met  with  by  the  projectile.  They 
are  found  lying  around  the  aperture  of  entry  into  the  bone. 

Most  free  splinters  come  from  the  bony  aperture  of  exit. 

6 


82         BONY  LESIONS  OF  THE  DIAPHYSES 

With  them  are  sometimes  found  spUnters  that  have  been 
set  free  from  the  lateral  walls  where  large  sphnters  have 
been  subdivided. 

These  free  splinters,  therefore,  cannot  exist  in  contact  fractures 
or  in  incomplete  perforations.  This  is  an  important  dictum 
which  surgeons  should  bear  in  mind. 

The  higher  the  velocity  of  the  projectile  causing  them, 
the  shorter  they  are.  In  the  great  majority  of  cases  they  corre- 
spond, as  we  have  before  remarked,  to  the  musculo-cutaneous 
CANAL  of  exit  in  which  the  hnllet  has  left  them. 

We  must  not  forget  that  this  musculo-cutaneous  canal 
extends  from  the  aperture  of  exit  in  the  bone  to  the  aperture 
of  exit  in  the  skin.  It  would  be  useless,  and  also  incom- 
prehensible, to  search  for  these  free  splinters  anywhere  else 
in  cases  that  have  been  wounded  by  ordinary  rifle-fire. 

The  greater  the  velocity  of  the  projectile,  and  also  the  more 
the  fracture  shows  comminution,  the  farther  these  splinters 
will  he  from  the  aperture  of  exit  in  the  hone. 

When  the  velocity  is  excessive,  free  splinters  are  no 
longer  carried  along,  but  are  violently  thrown  out  in  the  form 
of  a  sheaf.  They  no  longer  have  any  exact  situation,  they 
bury  themselves  in  the  soft  parts  at  a  more  or  less  long 
distance  from  the  track,  and  some  of  them  break  out  of  the 
limb  through  numerous  separate  orifices. 

2.  Adherent  Splinters. — These  correspond  to  the  parts 
of  the  bony  cylinder  that  the  projectile  has  not  touched. 

Free  splinters  are  short,  adherent  splinters  are  4,  6,  8,  10, 
and  even  20  centimetres  long. 

A  large  splinter  is  never  a  free  splinter^  hut  always  an  adherent 
splinter. 

Their  dimensions,  like  their  numher,  are  inversely  in  proportion 
to  the  velocity  of  the  projectile.  The  less  the  velocity,  the 
larger  the  adherent  splinters  and  the  less  their  number,  and 
inversely. 

The   firmness   of  their  adhesions  also   depends   on   the 


LESIONS  CA  USED  BY  PROJECTILES        83 

velocity  of  the  bullet.     The  less  the  latter,  the  firmer  the 
former. 

The  size  and  extent  of  these  splinters  are  in  close  relation- 
ship to  the  wounded  bone.  On  the  femur  and  the  tibia  they 
are  often  enormous ;  they  decrease  in  size  on  the  humerus, 
the  clavicle,  the  bones  of  the  forearm,  and  the  metacarpal 
and  metatarsal  bones. 

The  direction  taken  by  the  bullet  has  also,  in  this  connec- 
tion, a  certain  importance.  A  bullet,  the  direction  of  which 
is  nearly  that  of  the  axis  of  the  bone,  or  follows  it  (enfilad- 
ing fire),  gives  rise  to  longer  adherent  splinters  than  one 
that  strikes  perpendicularly. 

The  Osseous  Focus. — From  what  has  already  been 
said,  it  is  seen  that  the  osseous  focus  of  fracture  by  firearms 
presents,  in  the  large  majority  of  cases,  two  fragmentary  ex- 
tremities moulded  into  the  form  of  a  wedge  :  a  sharp  wedge 
(contact  fractures),  a  blunted  wedge  (perforations)  ;  also 
invariably  adherent  splinters  (all  fractures),  often  free  splinters 
(perforations). 

Splinters  increase  the  size  of  the  focus  by  4  to  20  centi- 
metres, habitually  by  6  to  8  centimetres.  Only  in  a  cleared- 
out  focus  (excessive  velocity)  is  there  loss  of  substance,  and 
even  then  it  is  very  trifling,  because  it  is  entirely  derived 
from  the  splinters.  The  length  of  the  bone  is  not  obviously 
diminished.  Even  in  these  cases  the  total  loss  of  substance, 
especially  when  considered  from  the  point  of  view  of  the 
two  cuneiform  fragments,  the  upper  and  the  lower,  does 
not  exceed,  in  spite  of  appearances,  2  centimetres. 

Notwithstanding  this  damage  done  to  the  bone,  even 
when  there  is  a  great  deal  of  comminution,  the  soft  parts 
have  suffered  the  more  injury  ;  but  we  know  how  easily  they 
undergo  repair. 

As  a  general  rule,  the  higher  the  velocity  of  the  projectile,  the 
more  limited  in  length  is  the  fracture,  hit  at  the  same  time  it  is 
more  comminuted. 


84        BONY  LESIONS  OF  THE  DIAPHYSES 

This  is  a  most  important  fact  which  we  include  amongst 
the  many  others  we  have  stated.  On  the  battlefield  it 
affords  a  key  to  the  nature,  the  importance,  the  intricacy  of 
the  assistance  we  have  to  render  in  cases  of  fracture. 

The  focus  shows  a  difference  according  as  the  bone  has  not 
sustained  a  solution  of  continuity,  or,  on  the  contrary,  according 
as  its  continuity  is  interrupted.  It  also  shows  a  difference 
according  as  (i)  the  focus  is  simple,  without  splinters  ;  (2)  or 
simple  with  stationary  splinters  that  have  not  been  displaced ; 
(3)  or  simple  with  splinters  that  have  been  displaced  and 
thrown  out. 

In  the  first  case  the  canal  of  exit  in  the  soft  parts  is 
narrow,  it  turns  on  itself  and  has  no  tendency  to  infection  ; 
in  the  second  case  it  is  zvidely  open,  much  contused  and  bleed- 
ing ;  in  the  third  case  it  may  reach  the  dimensions  of  the 
thumb  and  even  more,  it  may  admit  several  fingers  held 
close  together,  even  the  whole  hand.     It  is  much  inflamed. 

If  the  focus  of  a  fracture  by  firearms  is  comminuted, 
this  does  not  indicate  that  there  is  any  solution  of  continuity  of  the 
hone  itself.  In  this  connection  fractures  caused  by  firearms 
differ  entirely  from  the  fractures  seen  in  ordinary  practice  in 
which  comminution  is  always  accompanied  by  solution  of 
continuity. 

Diagnosis  of  Osseous  Lesions  of  the  Diaphyses. 

The  diagnosis  should  rest  on  two  points:  (i)  General 
diagnosis  of  the  osseous  lesion  ;  (2)  diagnosis  of  the  group  and  of 
the  variety. 

I.  General  Diagnosis. — Pain,  loss  of  all  power  in  the  limb, 
change  in  its  length  or  in  its  shape,  abnormal  mobility,  all  these 
points  can  be  of  use  to  us  in  fractures  by  firearms,  as  they 
are  in  ordinary  fractures,  in  establishing  a  general  diagnosis  ; 
but  as  many  of  these  signs  very  often  are  wanting,  we  are 
obhged  to  look  for   others.      The  following    are  the  signs 


DIAGNOSIS  OF  OSSEOUS  LESIONS  85 

we  consider  of  the  greatest  importance.  Radiography  has 
given  them  a  place  in  the  absolute  front  rank : 

They  are :  Shock  (comminuted  and  very  comminuted 
fractures). 

Pain  evoked  by  pressure  at  a  distance  or  on  the  supposed 
line  of  the  fissures. 

Angular  prominence  of  the  terminal  extremity  of  the  large 
splinters,  easily  felt  in  the  superficial  foci  (tibia,  ulna, 
clavicle),  and  sometimes  in  bones  situated  more  deeply,  even 
in  the  femur. 

Position  of  the  wounds  in  direct  relation  to  the  superficial 
bones  (hand,  foot,  tibia,  ulna,  clavicle). 

The  relation  of  the  track  in  the  soft  parts  to  the  position  of  the 
hones. 

The  enlarged  dimensions  of  the  aperture  of  exit  in  the  skin  and 
in  the  clothing  compared  with  the  aperture  of  entry  (short  and 
middle  range  firing). 

The  spread-out  form  of  certain  orifices  made  by  soft  lead 
bullets. 

Swelling,  profuse  hemorrhage  (the  bone  becoming  a  regular 
enormous  collection  of  blood).  This  sign  has  not  been 
sufficiently  dwelt  upon. 

Escape  of  small  oily  drops  (comminuted  fractures  of  the  big 
long  bones). 

The  presence  of  free  splinters  in  the  canal  of  exit,  at  the  level 
of  the  cutaneous  orifice,  or  that  of  the  clothes.  This  is  a 
favourable  sign. 

A  special  change  of  shape  of  the  projectile  (lateral  change  of 
shape,  bending  back  of  the  point),  even  when  the  aperture 
of  entry  shows  from  its  appearance  and  its  dimensions  that 
the  bullet  has  entered  from  point-blank  firing,  and  had  not 
been  deflected  nor  had  its  shape  altered. 

Extensive  crepitation,  which  is  obtained  by  bringing  the 
splinters  together ;  or  localized  crepitation,  obtained  by  slight 
compression  exercised  in   the  direction  of  the  aperture  of 


86        BONY  LESIONS  OF  THE  DIAPHYSES 

exit  in  the  bone.  These  are  quite  harmless  proceedings,  very- 
different  to  the  highly  reprehensible  plan  of  seeking  for 
crepitation  by  moving  the  whole  of  the  bone,  or  by  rotating 
the  fragments  ;  this,  indeed,  is  still  worse,  for  this  rotation 
easily  renders  complete  an  incomplete  fracture,  and  gives 
rise  to  displacements  which  are  diJfficult  to  correct. 

These,  then,  were  the  signs  we  brought  forward.  They 
well  maintain  their  value,  and  very  often  the  military 
surgeon  is  unable  to  obtain  others.  Under  favourable  con- 
ditions, at  the  rear,  radiography,  the  generalization  of  which 
becomes  more  and  more  necessary,  much  simplifies  nowa- 
days the  general  diagnosis. 

When  in  doubt,  we  should  act  as  if  the  fracture  existed, 
and  a  more  or  less  rapid  examination,  or  one  carried  out 
subsequently,  will  either  confirm  or  nullify  the  diagnosis. 

2.  Diagnosis  of  the  Group  and  of  the  Variety — 
(i)  Contact  Fractures. — We  have  given  as  principal  signs 
of  these  fractures :  absence  of  aperture  of  exit,  absence  of  very 
small  oily  drops,  absence  of  free  splinters  in  the  canal  of  exit, 
and,  the  best  sign  of  all,  absence  of  perforation  of  the  bone  or  of 
indentation,  this  having  been  proved  by  direct  exploration. 

Here  radiography  has  furnished  precise  indications  and 
simplified  research  after  these  last  two  valuable  signs.  In 
fact,  radiography  has  completed  the  clinical  history  of  this 
group. 

It  shows  in  these  contact  fractures  with  large  splinters — 
The  absence  of  splinters  in  the  canal  of  exit,  and,  above  all, 

the    PATHOGNOMONIC    SIGN  :    the    SHARP    WEDGE    OF    THE  TWO 

FRAGMENTS,  Upper  and  lower.  In  no  other  kind  of  fracture 
caused  by  firearms  is  this  sign  to  be  found. 

(2)  Fractures  by  Perforation. — Radiography  settles  the  diag- 
nosis of  fractures  by  perforation  of  one  wall  of  the  bone. 

Fractures  by  perforation  of  the  two  walls  of  the  bone  are 
recognized  by  the  rectilinear  track  in  the  axis  of  the  bone,  by  the 
enlargement  of  the  aperture  of  exit  in  the  soft  parts  and  in  the 


DIAGNOSIS  OF  OSSEOUS  LESIONS  87 

clotheSj  by  the  presence  of  free  splinters  close  to  the  cutaneous 
aperture  of  exit  or  else  in  the  track  of  exit,  by  multiple  orifices 
(explosive  fire),  by  the  change  in  shape  of  the  point  of  the 
bullet,  by  splitting  up  of  those  bullets  that  have  an  envelope, 
by  the  localized  crepitation  in  the  focus  of  free  splinters  near  the 
aperture  of  exit  in  the  hone. 

Thanks  to  these  signs,  the  diagnosis  of  the  lesion  is 
generally  easy.  Radiography  has  made  it  still  easier  by 
disclosing  (i)  when  there  is  no  solution  of  continuity,  the 
ROUNDED  OR  OVAL  PERFORATION  the  diaphysis  has  sustained 
in  the  first  v^^all  that  has  been  pierced,  the  more  irregular 
but  as  easily  demonstrated  loss  of  substance  in  the  second 
wall;  (2)  when  there  is  solution  of  continuity,  and  even 
considerable  displacement  of  the  fragments,  the  indentation 
presented  by  the  superior  and  inferior  cuneiform  fragments  ;  finally 
(3)  in  both  cases  the  presence  of  numerous  free  splinters, 
either  lying  in  the  canal  of  exit  or  moved  into  a  new  position. 
(3)  Fracture  by  Groove. — These  fractures  were  very  difficult 
to  diagnose  before  the  advent  of  radiography. 

The  circular  nature  of  the  track,  occasionally  the  slight 
change  of  shape  of  the  bullet  (lateral  parts  and  apex),  the 
small  free  splinters  in  the  canal  of  the  wound,  and  especially 
the  verification  by  the  finger  of  a  peripheric  osseous  groove, 
were  the  signs  met  with. 

Radiography  renders  the  following  pathognomonic  sign 
perfectly  clear :  peripheric  indentation  in  the  osseous 
track  of  hard  lead  bullets  with  an  envelope  (German  and 
Austrian  bullets).  These  tracks  are  rendered  evident  by 
small  seed-like  particles  of  lead  when  the  bullet  has  become 
separated  from  its  covering. 

Comminution  is  easily  recognized.  It  is  shown — (i)  By 
multiplied  loud,  fine  crepitation  of  free  splinters,  very 
different  with  regard  to  sensation  and  to  sound  from  the 
extensive  crepitation,  more  muffled  and  not  multiplied, 
caused    by   the   friction   of    the   long    adherent    splinters. 


88        BONY  LESIONS  OF  THE  DIAPHYSES 

(2)  By  the  presence  of  a  large  number  of  splinters.  We 
must  also  remember  that  in  war  surgery  grave  comminu- 
tion and  a  solution  of  continuity  are  not  synonymous. 

Not  only  has  radiography  thrown  light  on  the  general 
diagnosis  of  these  fractures,  and  allowed  us  to  establish  the 
diagnosis  of  the  different  groups,  but  every  day  it  enables 
us  to  identify  metallic  foreign  bodies,  whole  bullets  that 
have  lost  their  shape  or  become  subdivided,  and  have  been 
arrested  in  the  osseous  focus  or  in  the  neighbouring  soft 
parts  after  having  caused  the  fracture  of  the  diaphysis. 

We  have  already  described  many  of  these  changes  of 
shape,  but  in  doing  so  we  always  had  before  our  eyes  the 
changes  of  shape  that  result  from  contact  with  hard  soil 
before  reaching  the  human  body.  Now  we  have  to  deal 
only  with  those  that  result  from  contact  with  bone. 

Changes  of  Shape  in  Bullets  that  have  struck  Bones. — i.  Soft 
lead  bullets  that  have  caused  fractures  by  contact  are 
flattened  out,  and  often  take  on  the  shape  of  the  bones  they 
have  struck.  According  to  the  bone  it  has  reached,  the 
bullet  IS  flattened  or  concave. 

2.  It  is  the  same  thing  with  hardened  lead  bullets  that 
have  an  envelope.  The  change  of  shape  consists  especially 
in  flattening  of  the  apex,  with  or  without  separation  from  the 
envelope ;  but  in  these  cases,  again,  the  surface  is  flat  or 
concave. 

3.  With  bullets  composed  of  one  piece,  such  as  the 
D  bullet,  the  change  of  shape  is  insignificant. 

In  PERFORATIONS,  both  soft  lead  bullets  and  hardened  lead 
bullets  with  an  envelope  become  flattened,  are  compressed,  and 
become  bent  from  the  apex  to  the  base.  The  flattened  surface  of 
the  apex  is  rendered  irregular.  The  increase  of  diameter, 
consequent  on  the  compression,  results  in  enlargement  of 
the  bony  aperture  of  exit,  in  the  liberation  of  more  splinters, 
and  also  in  enlargement  of  the  aperture  of  exit  in  the  soft 
parts. 


DIAGNOSIS  OF  OSSEOUS  LESIONS  89 

Though  less  marked,  the  changes  of  shape  in  the  D 
bullet  are  analogous,  but  do  not  present  any  notable  irregu- 
larity in  the  surface  of  the  turned-back  apex. 

With  GROOVES,  the  changes  in  the  shape  of  the  bullets  are 
insignificant. 

Foreign  Bodies  derived  from  the  Clothes. — Diagnosis  of  foreign 
bodies  derived  from  the  clothes  is  rendered  certain  by  in- 
spection of  the  clothes  which  at  the  aperture  of  entry  show  loss 
of  substance,  and  indicate  the  number  and  the  dimensions 
of  the  pads,  consisting  of  pieces  of  clothing,  that  are  in  the 
wound.  The  surgeon  should  never  forget  to  make  this  examination. 
The  enlarged  aspect  of  the  aperture  of  entry  will  alone 
determine  the  probability  of  the  sojourn  of  these  infecting  bodies 
in  the  focus  ;  on  the  other  hand,  increase  in  size  of  the 
apertures  of  exit  is  a  sign  that  makes  us  presume  the  existence 
of  a  lesion  of  bone. 

Prognosis,  Progress,  Evolution. 

One  of  the  most  precise,  as  well  as  one  of  the  most 
comforting,  data  that  has  been  furnished  us  during  the 
wars  that  took  place  at  the  end  of  last  century  and  at  the 
beginning  of  this  is  the  fall  of  the  percentage  in  the 
prognosis  of  fractures.  The  mortality  oscillated  between 
one-fifth  and  one-half,  and  the  usual  treatment  was  amputa- 
tion. Nowadays,  the  smaller  diameter  of  the  bullets,  the 
much  less  frequent  occurrence  of  infection,  together  with 
smaller  apertures,  and  the  less  common  movements  of  pieces 
of  clothing  to  various  parts  of  the  wound,  quicker  first  aid, 
and  the  application  of  modern  dressings,  have  not  only 
modified  the  prognosis,  but  also  the  progress  and  ultimate 
result  of  fractures.  At  Karbine,  amongst  2,845  cases  of 
fracture,  there  were  39  deaths. 

With  pointed  bullets  that  have  not  been  deflected,  progress 
is  aseptic  or  very  slightly  septic. 

Some  fractures  may  heal  like  an  ordinary  simple  fracture, 


go        BONY  LESIONS  OF  THE  DIAPHYSES 

but  this  is  rare.  Many  heal  after  insignificant  suppuration, 
without  the  slightest  doubt  occurring  as  to  the  advisability 
of  preserving  the  free  splinters,  whose  ablation  up  to  quite 
recently  was  regarded  as  a  dogma. 

In  a  large  number  of  cases  it  is  after  a  rapid,  slight 
suppuration,  and  the  removal  of  these  splinters,  if  their 
presence  really  cannot  be  tolerated,  that  a  cure  is  obtained. 
The  bone  retains  its  length,  and  its  shape  is  soon  restored  ; 
the  joints  rapidly  regain  their  mobility.  Badly  formed 
callus  would  point  to  incompetence  on  the  part  of  those 
who  have  treated  the  fracture.  What  we  have  described 
is  the  usual  course  of  these  traumatisms :  slight  and  calm 
reaction,  very  soon  arrested  in  cases  of  fracture  caused  by 
pointed  bullets. 

The  foci  of  very  comminuted  fractures,  of  those  produced 
by  deflected  bullets,  by  bullets  from  shrapnel  or  shell  splinters, 
axe  seats  of  infection  from  the  very  beginning,  and  contain 
remnants  of  clothing  which  in  themselves  are  infectious  to 
the  highest  degree  ;  these  foci  undergo  sharper  reaction 
and  present  more  abundant  suppuration,  complicated  by 
purulent  outshoots.  Sacrifice  of  the  free  splinters  then 
rapidly  becomes  a  necessity,  and  the  utility  of  such  a 
measure  is  proved  by  diminution  of  these  symptoms  so 
soon  as  the  removal  of  these  bodies  is  effected  and  the 
focus  carefully  disinfected,  especially  by  the  use  of  hydrogen 
peroxide,  of  5  per  cent,  solutions  of  carbolic  acid,  of  10  per 
cent,  chloride  or  permanganate  solutions,  but,  above  all,  by 
pure  hydrogen  peroxide.  Afterwards  all  will  go  on  well, 
provided  the  wounded  man  is  in  the  hands  of  a  skilled 
surgeon. 

However,  the  foregoing  description  cannot  make  us  forget 
that  much  delayed  dressing,  the  presence  of  unsuspected 
foreign  bodies,  and  unskilled  care  of  the  wounded  man, 
render  the  lesion  liable  to  dangerous  suppuration.  Per- 
ipheral suppuration  then  becomes  extensive,  it  reaches  the 


PROGNOSIS,  PROGRESS,  EVOLUTION        91 

focus,  the  fissures,  the  multiple  subperiosteal  seats  of  separa- 
tion ; '  the  free  splinters  play  the  part  of  foreign  bodies, 
adherent  splinters  become  free,  and  if  the  wounded  man 
does  not  rapidly  succumb  to  diffuse  suppuration  or  to  osteo- 
myelitis, these  complications,  either  the  one  or  the  other,  in 
addition  to  the  extremities  of  the  fragments  that  have 
become  sequestra,  maintain  persistent  fistulae  and  tedious 
suppuration. 

It  may  he  stated,  and  move  especially  with  regard  to  soldiers 
with  fractures,  that  the  fate  of  these  men  depends  more  or  less  on 
the  skill  of  those  who  treat  them. 

These  cases  should  always  he  put  under  a  surgeon  who  has 
acquired  a  certain  reputation. 

Extensively  comminuted  fractures  are  not  as  a  rule  more 
serious  than  fractures  of  a  less  complicated  type,  nor  is 
their  treatment  more  difficult,  this  being  contrary  to  what 
might  be  conjectured  in  the  absence  of  precise,  if  tardy, 
observations.  We  have  even  remarked  a  fact  which  seems 
paradoxical,  that  comminuted  fractures — that  is  to  say,  those 
with  very  subdivided  lateral  splinters — present  in  young, 
well-fed  men  who  have  not  suffered  many  hardships,  and 
who  are  well  cared  for,  particularly  favourable  conditions 
towards  consolidation.  This  may  be  explained  by  pointing 
out  that  through  the  lines  of  fissure,  much  multiplied  in 
these  cases,  the  osteogenetic  cells  of  the  periosteum  pro- 
liferate in  larger  numbers,  and  on  to  a  greater  number  of 
points,  than  in  fractures  of  a  simpler  type,  and  one  is  quite 
surprised  to  observe  in  a  very  short  time  exuberances  of 
callus,  which,  moreover,  are  very  quickly  reduced  to  a 
definite  formation. 

Immediate  or  Late  Complications.  —  i.  Primary 
hemorrhage,  although  it  may  not  come  from  a  large  vessel,  is 
frequent  in  fractures  of  the  large  long  bones.  Plugging  of  the 
wound  is  often  necessitated.  But  plugging  has  its  serious 
disadvantages.     If  it  is  maintained  for  too  long  a  time,  a 


92        BONY  LESIONS  OF  THE  DIAPHYSES 

few  days,  it  prevents  the  wound  getting  rid  of  its  excreta, 
and  leads  very  often  to  diffuse,  putrid,  or  gangrenous  inflamma- 
tion. This  was  proved  in  Manchuria,  and  also  during  the 
Balkan  War.  Everything  must  be  done  to  prevent  the 
recurrence  of  a  similar  experience. 

2.  Gangrene. — Nowadays  we  constantly  hear  it  repeated 
that  gangrene  is  an  infection.  Almost  all  existence  is  denied 
to  traumatic  gangrene,  and  we  seem  nearly  to  have  forgotten 
the  form  of  gangrene  which  is  the  result  of  great  con- 
striction, exercised  by  the  apparatus  put  on  to  facilitate  the 
patient's  transport.  We  are  wrong.  All  this  exists. 
Traumatic  gangrene  is  undeniable ;  gangrene  by  compres- 
sion, resulting  from  mechanical  arterial  anaemia  (garrot), 
must  not  be  forgotten.  The  garrot  stops  arterial  haemor- 
rhage ;  its  object  has  been  carried  out.  Excellent !  But  if 
the  instrument  is  kept  on  beyond  the  exact  time  necessary 
to  obtain  this  result,  and  on  a  limb  the  circulation  in  which 
is  already  imperilled  by  the  presence  of  the  arterial  lesion, 
gangrene  is  quickly  brought  about.  An  apparatus  may 
admirably  retain  bandages  and  dressing  in  place  during 
transport,  well  and  good,  but  it  must  be  watched  during 
the  transport,  and  the  transport  must  not  last  too  long,  or 
gangrene  will  appear. 

Both  traumatic  gangrene  and  gangrene  by  compression 
are  seen  in  these  fractures.  These  complications  nearly 
always  come  on  from  the  second  to  the  fifth  day.  We  have 
seen  most  regrettable  cases  of  this  kind.  Under  these  cir- 
cumstances amputation  is  necessary,  except  when  the 
gangrene  is  only  partial. 

3.  Foreign  Bodies. — We  return  to  the  subject  merely  to 
call  attention  to  their  frequency,  to  stigmatize  the  bad 
surgery  of  extracting  them  too  soon  and  under  defective 
surrounding  conditions,  when  it  is  a  question  of  rifle  bullets. 

Shrapnel  bullets  and  shell  splinters  should  be  removed  during 
the  first  regular  dressing. 


PROGNOSIS,  PROGRESS,  EVOLUTION        93 

4.  Stippuration.—lt  originates  nearly  always  in  the  neigh- 
bourhood of  the  focus  occupied  by  splinters,  and  from  here 
its  greatest  diffusion  is  carried  on.  Issue  should  be  given 
to  the  pus  by  large  incisions,  which,  in  principle,  should 
correspond  to  the  aperture  of  exit.  Suppuration  rapidly 
appears,  generally  during  the  first  eight  days. 

In  wounds  by  shrapnel,  shell  splinters,  and  deflected 
bullets,  suppuration  is  habitual ;  therefore,  to  provide 
against  such  an  accident,  wounded  men  suffering  from  any  of 
these  traumatisms  should  not  he  carried  long  distances  at  a  stretch, 
but  should  undergo  successive  evacuation  of  the  pus  as 
we  have  suggested,  and  as  soon  as  possible  they  should  be 
placed  under  the  supervision  and  treatment  of  a  surgeon. 

5.  Osteomyelitis. — Up  to  the  time  of  recent  campaigns, 
osteomyelitis  was  the  most  frequent  and  the  most  serious 
complication  of  osseous  lesions  caused  by  firearms.  Let 
us  at  once  state  that  it  has  become  relatively  rare. 

Insufficient  and  unsuitable  food,  overcrowding,  lack  of 
proper  and  regular  treament,  all  these  prepare  the  soil  for 
infection. 

Osteomyelitis  in  most  cases  shows  itself  about  a  week 
after  the  traumatism,  often  during  the  first  fifteen  days,  by 
the  advent  of  fever,  prostration,  sharp  pain  when  the  medul- 
lary canal  is  not  open.  The  limb  is  very  swollen,  oedematous, 
red,  hard,  and  feeling  like  wood.  On  deep  palpation  it  is 
very  difficult  to  identify  sub-periosteal  collections.  In  the 
focus  of  a  fracture  widely  open,  the  periosteum  is  easily 
separated  from  the  bone,  and  a  red,  mushroom-like  bud  is 
seen  coming  out  of  the  medullary  canal.  The  general  signs 
are  those  of  typhus  affections  and  of  purulent  or  putrid 
infection. 

The  subacute  or  chronic  form  presents  very  extensive 
thermic  oscillations,  slight  pain,  a  similar  hard  puffiness, 
similar  collections  of  pus,  similar  sub-periosteal  and  deep 
suppuration,  and  later  on    articular   and  parenchymatous 


94        BONY  LESIONS  OF  THE  DIAPHYSES 

pains  and  swellings,  symptomatic  of  metastatic  collections 
(shoulder,  knee^  lungs,  liver,  kidneys). 

Cure  can  only  possibly  be  obtained  by  very  active  treat- 
ment, which  includes  sub-periosteal,  deep,  and  rapid 
incisions,  antiseptic  washing  out,  the  use  of  iodoform 
gauze ;  the  internal  remedy  is  sulphate  of  quinine  in  large 
doses  (A.  Guerin).  If  no  success  is  obtained  by  these 
means,  we  must  trephine  the  medullary  canal,  if  it  is  not 
already  open  ;  if  it  is  open,  it  must  be  scraped  out,  or  dis- 
articulation performed. 

Treatment  of  Fractures  of  the  Diaphysis  caused  by 

Firearms. 

Conservatism  is  the  rule  in  the  treatment  of  these  fractures. 
This  is  a  precept  which  ought  to  be  written  in  big  letters 
at  the  door  of  every  sanitary  establishment. 

Conservatism  includes — (i)  Immobilization  of  the  limb  ; 
(2)  reduction  of  the  fracture  and  maintaining  it  in  position  after 
reduction ;  (3)  dressing  the  wound ;  (4)  consecutive  care  and 
nursing. 

I.  Immobilization. — Immobilization  differs  according  to 
where  the  wounded  man  is  found. 

(a)  On  the  battlefield,  and  during  the  transport  of  the 
patient  to  the  ambulance,  immobilization  is  obtained  by 
temporary  apparatus  constructed  of  what  the  soldier  has 
on  his  person,  or  of  parts  of  his  equipment  or  of  his  kit, 
and  also  of  the  materials  carried  by  the  stretcher-bearers 
or  by  the  ambulance  men. 

For  the  upper  limb,  a  handkerchief,  a  scarf,  the  lappet  of 
the  overcoat  raised  up  and  fixed  to  the  shoulder  (Delorme), 
will  support  the  forearm ;  the  neck-cloth  (French  soldiers) 
or  the  neck  comforters  now  in  use  (English  soldiers), 
first  spread  out  and  then  rolled  to  form  a  bandage,  will  fix 
the  humerus. 

For  the  lower  limb,  the  blanket,  the  rolled  canvas  of  the 


Fig.  13.— Delorme's  Valvular  Metallic  Gutter  Splints  for 
Fracture  of  the  Diaphysis  and  for  Articular  Lesions 
OF  the  Upper  and  Lower  Limbs. 


96        BONY  LESIONS  OF  THE  DIAFHYSES 

portable  tent  (French  soldiers).  The  rifle  kept  in  place  by 
straps  or  belts,  whose  use  has  been  so  much  recommended, 
will  be  replaced  by  fixing  the  healthy  limh  against  the 
wounded  limh^  keeping  both  in  position  by  bandages  above 
and  helow  the  knee  and  on  a  level  with  the  instep. 

{h)  At  the  movable  or  fixed  ambulance,  the  same 
methods  should  be  employed,  together  with  the  many 
varieties  of  combined  bandages,  simple  splints,  and  iron 
wire  gutter  apparatus,  all  of  which  are  carried  by  the 
various  ambulances,  and  approach  more  or  less  to  the 
final  apparatus. 

These  apparatus  must  realize  the  conditions  on  which  we 
have  laid  stress  :  simple  construction,  capacity  fov  quick  applica- 
tion, sufficient  strength  to  keep  the  parts  reduced  and  well  together. 

We  cannot  too  highly  recommend  the  employment  of  the 
straw  apparatus  of  Pare  and  Larrey,  small  trusses  held 
together  at  certain  intervals  by  twine ;  these  apparatus  are 
both  stiff,  flexible,  and  elastic,  and  are  quite  capable  of 
maintaining  the  parts  in  their  proper  position ;  besides,  they 
are  easily  prepared  beforehand.  They  should  be  sur- 
rounded by  a  clean,  thick  piece  of  linen,  and  fixed  on  the 
limb  over  the  clothes. 

Apparatus  for  Transport. — In  many  fractures  the  patient 
should  not  be  transported.  These  are  cases  in  which  the 
fracture  presents  a  grave  solution  of  continuity  complicated  by 
hemorrhage,  by  foreign  bodies,  or  by  comminution.  Fractures 
of  the  thigh,  particularly,  are  amongst  those  that  should  be 
treated  on  the  spot.  In  some  cases,  however,  transport  is  an 
absolute,  though  hard,  necessity.  On  the  other  hand,  there 
is  nothing  to  prevent  the  transport  of  many  others, 
especially  of  those  with  fractures  of  the  upper  limb,  but 
always  on  the  understanding  that  the  apparatus  which 
holds  the  parts  in  position  be  appropriate  and  properly 
applied. 

As   the   apparatus  made  use  of  must,  in  principle,  be 


TREATMENT  OF  FRACTURES  97 

stowed  in  the  transport  waggons  of  the  ambulance  service, 
they  should  not  be  very  weighty.  They  should  also  be 
simple  in  construction,  easily  and  quickly  applied,  and 
should  insure  the  holding  of  the  parts  very  exactly  in 
position  ;  in  fact,  they  must  be  removable,  yet  irremovable 
(Delorme). 

Innumerable  have  been  the  apparatus  proposed ;  many 
of  them  have  found  a  place  in  our  waggons,  such  as 
apparatus  of  pierced  tin-plate,  wooden  splints,  splints  composed  of 
a  network  of  iron  wire,  rolls  of  metallic  cloth.  They  are  all 
useful,  strictly  speaking,  in  dealing  with  the  upper  limbs 
whose  fractures  are  more  often  without  displacement. 

Mayor's  iron  wire  gutter  apparatus  is  heavy  and  cumber- 
some ;  it  takes  up  a  great  deal  of  room  in  the  waggons 
necessitates  a  large  amount  of  material  for  padding,  and 
does  not  immobilize  properly.  The  drawbacks  are  well 
known.  Why,  then,  is  this  apparatus  still  used  ?  The 
occasion  has  now  come  for  it  to  be  definitely  abandoned. 

Plaster  apparatus  and  splints  are  a  long  time  getting  dry, 
and  their  application  is  very  slow  and  tedious ;  the  plaster 
used  is  not  always  of  good  quality  ;  they  are  not  sufficiently 
strong  and  firm  to  be  utilized  during  transport  unless  they 
are  strengthened  in  some  way ;  moreover,  they  labour  under 
the  very  serious  disadvantages  of  being  irremovable,  of  not 
yielding  to  the  swelling  of  the  limb,  which  may  undergo  rapid 
and  great  dilatation,  and  this  may  give  rise  to  gangrene. 
Therefore  plaster  apparatus  are  condemned  by  most  army 
surgeons. 

De  Moy's  gutter  splint  with  valves  would  be  excellent, 
were  it  not  so  expensive,  and  if  it  were  impermeable.  Its 
principle  is  very  good.  Sarrazin's  hollowed  apparatus  in 
metallic  network  with  valves  is  too  complicated,  and  its  storage 
is  difficult. 

The  zinc  gutter  splints  should  be  preferred.  The  metal  is 
very  malleable,  and  does  not  become  oxidized ;  the  cost  of 

7 


98         BONY  LESIONS  OF  THE  DIAPHYSES 

the  apparatus  is  small.  For  the  upper  limb,  the  model  of 
Champenois  has  given  proof  of  its  utility.  That  of  Henne- 
quin  transformed  into  a  zinc  apparatus  is  a  little  complicated 
with  regard  to  transport,  and  the  extension  it  is  supposed  to 
produce  should  not  be  relied  on.  The  apparatus  of  Raoult- 
Deslonchamps  are  excellent  in  common  fractures,  for  the 
treatment  of  which  they  were  originally  constructed.  How- 
ever, they  do  not  allow  of  easy  supervision  of  the  limb,  nor  of 
easy  renewal  of  the  dressings.  Struck  by  these  desiderata, 
we  have  utilized  some  of  the  apparatus  from  the  lower  limb 
in  constructing  for  the  upper  limb  models  which  are 
accepted  everywhere,  and  have  their  place  in  our  ambulance 
supplies. 

The  Minister  of  War  has  just  had  these  models  forwarded 
to  all  our  ambulances,  whether  in  the  front  or  in  the  rear. 

Their  storage  is  easy,  as  they  are  carried  in  superposed 
sheets  of  metal ;  they  take  up  but  very  little  room  ;  they  are 
very  easily  moulded  to  the  limbs  with  the  employment  of  a 
minimum  of  material,  and  even  without  any  padding  ;  they 
serve  equally  for  either  limb;  they  can  be  applied  rapidly, 
thanks  to  their  system  of  fixing,  and,  with  the  help  of  their 
valves,  they  render  very  easy  both  the  supervision  of  the 
limb  and  the  application  of  dressings.  Why  should  our 
interest  in  these  apparatus,  on  account  of  our  having  given 
them  birth,  prevent  us  from  expressing  our  candid  opinion 
and  stating  all  the  good  that  is  thought  of  them  ?  Facts 
speak  for  themselves.  These  apparatus  have  unquestionably 
shown  themselves  to  be  superior  to  any  others,  and  deserve 
to  be  placed  in  the  first  rank  of  methods  of  immobilization 
both  during  transport  and  during  the  final  treatment. 

Definitive  Apparatus. — We  expect  these  apparatus,  em- 
ployed in  the  rear,  to  carry  out  the  following  points : 
(i)  Suitable  immobilization  of  the  fractuve ;  (2)  to  allow  proper 
supervision  of  the  limb  ;  and  (3)  easy  application  of  dressings. 

Plaster    apparatus,  those  for  continuous    extension,   the 


TREATMENT  OE  FRACTURES  99 

gutter^  splints  of  metallic  network,  are  easy  to  apply, 
but  very  deficient  with  regard  to  retaining  the  fracture  in 
position;  they  are  preferred  by  many  surgeons  who  are 
accustomed  to  use  them.  None  of  these  apparatus  allow 
easy  supervision  of  the  limb,  nor  especially  the  easy  renewal 
of  the  dressings,  coaptation  of  the  splinters,  and  mobiliza- 
tion of  the  articulations.  They  are  very  inferior  to  the 
gutter  splints  with  valves,  that  we  can  hardly  recommend 
too  much. 

2.  Reduction  and  keeping  in  Place  of  the  Fracture 
— In  ordinary  fractures  reduction  is  an  important  procedure, 
because  the  external  violence  has  nearly  always  caused 
great  displacement,  which  itself  is  facilitated  by  the  form  of 
the  fracture.  In  fractures  by  firearms  it  is  not  at  all  the 
same  thing.  In  the  upper  limb  displacement  is  very  often 
absent,  and  is  generally  of  little  importance ;  in  the  lower 
limb  it  is  likewise  very  often  absent,  excepting,  however,  in 
the  thigh,  where  abduction  and  external  rotation  of  the  limb 
seem  to  be  the  rule. 

A  long  time  ago  we  drew  attention  to  the  fact  that  in 
fractures  by  firearms  reduction  following  the  axis  of  the 
limb  was  not  the  last  word,  but  that  it  was  necessary  to 
combine  with  it  coaptation  of  the  large  splinters,  their  tight 
junction  with  the  extremities  of  the  fragments  to  which  they  must 
correspond.  It  is  first  by  manual  pressure,  and  afterwards  by 
pressure  exercised  with  pads  of  cotton- wool  placed  laterally, 
that  these  results  are  obtained. 

This  pressure  should  be  made  in  a  perpendicular  direction 
to  the  track  of  the  projectile.  Very  often  it  is  indispen- 
sable. It  reduces  the  dimensions  of  the  focus  of  the  fracture, 
contributes  to  more  complete  and  firmer  coaptation,  and 
allows  us  to  obtain  a  more  regular  callus. 

3.  Dressing  the  Wound. — In  administering  first  aid, 
and  even  during  the  first  few  moments  at  the  ambulance, 
the  fracture  will  be  immobilized,  and  the  wound  dressed 


loo       BONY  LESIONS  OF  THE  DIAPHYSES 

without  removal  of  the  patient's  clothes.  We  should  con. 
tent  ourselves  with  cutting  the  latter  so  as  to  form  kinds 
of  shutters,  without,  however,  destroying  the  orifices  already 
made.  The  first  dressing  will  be  applied  over  the  parts 
uncovered  by  the  cuts  we  have  made  in  the  garments. 

At  the  ambulance  this  provisional  dressing  will  be  re- 
placed by  a  complete  dressing,  after  thorough  asepsis  of 
the  wound  and  its  neighbourhood  has  been  obtained  by  the 
use  of  iodine.  The  wound  will  then  be  covered  with  the 
usual  dry  hospital  dressing.  Damp  or  wet  dressings  must 
be  banished. 

Formerly  we  were  taught  that,  at  the  ambulance,  removal 
of  free  splinters,  either  by  enlargement  of  the  wound  or  by 
slitting  any  constricting  tissues,  should  precede  the  applica- 
tion of  the  dressings.  Nowadays  it  is  considered  better  to 
leave  these  splinters  alone  ;  but  they  have  to  be  removed 
should  suppuration  come  on  in  the  wound. 

Antisepsis  of  the  infected  foci  should  be  secured  (see 
suppuration).  Washing  with  peroxide  of  hydrogen,  with 
solution  of  carbolic  acid  (5  per  cent.)  or  with  ether,  touching 
with  chloride  of  zinc  solution  (i  per  cent.)  or  with  iodine, 
iodoform  gauze  dressing,  etc.,  will  then  be  very  useful. 

Suppuration  necessitates  incisions,  followed  by  drainage. 
In  making  these  incisions,  we  should  give  preference  to  the 
aperture  and  the  canal  of  exit ;  it  is  here  we  shall  find 
splinters  and  irritating  foreign  bodies.  We  must  not  hesitate 
to  make  free  and  extensive  incisions. 

Other  incisions  should  be  made  so  far  as  possible  to 
follow  the  classical  incisions  for  the  ligature  of  arteries. 

A  practice,  in  all  ways  most  regrettable,  and  which  we 
thought  had  been  definitively  condemned,  for  it  undoubtedly 
is  by  all  those  who  are  familiar  with  the  requirements  of 
war  surgery,  is  one  that  consists  in  introducing  into  the 
canal  of  the  wound  an  aseptic  or  antiseptic  gauze  or  other 
drain  that  blocks  up  the  opening.     This  proceeding  is  still 


TREATMENT  OF  FRACTURES  loi 

employed  in  the  present  day  by  skilled  surgeons,  and  even 
by  some  who  have  a  big  name.  We  cannot  possibly  con- 
demn it  sufficiently.  We  cannot  now  return  to  the  argu- 
ments, to  the  long  discussions  that  have  continued  for  so 
long  a  time  on  "  drains  and  tents,"  from  Pare  to  the  present 
day.  The  subject  is  exhausted,  opinion  is  laid  down.  The 
practice  is  a  mistake — a  most  pernicious  mistake.  The 
Russian  surgeons  during  the  Manchurian  War,  and  those 
who  took  part  in  the  Balkan  War,  condemned  its  use  after 
a  trial  that  they  bitterly  regretted.  Our  wounded  should 
not  have  to  bear  the  disadvantages  of  fresh  unjustifiable 
trials.  Putting  a  drain  into  the  focus  of  a  fracture  may  be 
compared  to  shutting  the  wolf  up  in  the  sheepfold  ;  seriously, 
it  is  exposing  the  wounded  man  to  most  grave  complications. 

4.  Consecutive  Care  and  Nursing. — Large  and  irregular 
pieces  of  callus  were  rather  frequent  in  the  old  days.  Now- 
adays they  are  far  less  common.  In  most  cases  they  indicate 
incapacity  of  surgical  treatment. 

Pseudo-arthroses  are  less  seen  since  we  have  more  respected 
the  adherent  splinters,  which  were  condemned  to  be  partly 
sacrificed  at  a  time  when  the  removal  of  the  free  splinters 
was  recommended. 

Painftil  callus  is  connected  either  with  compression  of 
nerve-trunks  that  have  been  surrounded  by  callus,  with 
irritation  set  up  by  foreign  bodies,  or  with  osteitis.  In 
fractures  of  the  humerus,  the  musculo  -  spiral  nerve  is 
particularly  predisposed  to  compression. 

Foreign  bodies,  whose  situation  is  easily  made  out,  are 
removed  nowadays  without  hesitation  and  without  much 
damage. 

Persistent  osfeiiic  foci  necessitate  gouging  and  scraping. 

Nowadays,  when  the  vital  question  no  longer  comes  into 
play,  and  when  the  treatment  of  fractures  has  become  much 
easier,  we  must  endeavour  to  attain  perfection  in  our 
definite  results, 


102       BONY  LESIONS  OF  THE  DIAPHYSES 

The  use  of  mineral  waters  is  quite  indicated  after  the 
fracture  is  consolidated.  Massage,  and  methodical  move" 
ment  of  the  joints,  especially  mechano-therapy,  become  a 
necessity.  Bourbonne-les-Bains,  Dax,  Aix,  and  specially 
Vichy,  whose  mechano-therapeutic  installation  is  admirable, 
will  render  great  help  in  the  treatment  of  the  sequelae  of 
fractures.  So  soon  as  their  fractures  are  consolidated,  the 
patients  should  he  sent  to  such  establishments. 

Resection  of  the  Diaphyses. — This  is  a  very  old  opera- 
tion, which  consisted,  in  fractures  by  firearms,  in  removal  of 
all  the  splinters,  both  adherent  and  free,  and  resection  of  the  cunei- 
form extremities  of  the  fragments.  This  operation  necessitated 
a  tremendous  amount  of  damage  to  the  parts,  prolonged  the 
cure,  promoted  pseudo-arthrosis,  and  brought  in  its  train 
severe  functional  weakening.  It  has  been  abandoned.  It 
gave  lamentable  results  during  the  American  War  of 
Secession  and  during  the  German  wars. 

Amputation. — Amputation  should  be  reserved  primarily 
for  large  traumatisms  of  bone,  with  great  destruction  of  the 
soft  parts  and  recognized  gangrene ;  consecutively,  it  may  be 
forced  on  us  by  persistent  suppuration,  extensive  chronic 
osteitis.  Besides,  it  must  remain,  without  the  shadow  of  a 
doubt,  in  the  surgeon's  opinion  as  the  only  possible 
alternative. 


CHAPTER  VIII 
LESIONS  OF  THE  ARTICULATIONS 

In  lesions  of  the  joints  we  may  include — Periarticular,  or 
non-penetrating,  wounds ;  simple  penetrating  wounds  ;  penetrating 
wounds  with  osseous  lesions. 

Periarticular  Wounds. — They  have  the  same  charac- 
teristics as  wounds  of  the  soft  parts  of  all  regions.  The 
only  general  peculiarities  that  deserve  to  be  noticed  are — 
(i)  those  that  concern  the  opening  of  tendinous  sheaths  or 
of  periarticular  serous  bursse  which  may  convey  the  idea  of 
a  penetrating  lesion,  whilst  in  reality  the  soft  parts  only  are 
affected  ;  and  (2)  the  danger  of  haemorrhage  in  regions  where 
the  anastomotic  circles  are  more  especially  developed.  Let 
us  finally  draw  attention,  with  regard  to  periarticular 
wounds,  to  certain  lesions  of  the  bony  apophyses  that  do 
not  penetrate  the  articulation.  The  present  hdlets  do  not  make 
contour  wounds. 

Simple  Penetrating  Wounds.— These  are  penetrations 
of  the  synovial  membrane  without  osseous  lesions.  They 
are  rare,  and  are  only  seen  in  the  shoulder  and  knee-joints. 
In  the  shoulder  because  here  the  loose  capsule  may  leave, 
for  the  passage  of  projectiles,  a  certain  interval  between  the 
glenoid  cavity  and  the  head  of  the  humerus ;  in  the  knee  on 
account  of  the  great  extent  of  the  synovial  cul-de-sac  under 
the  quadriceps  extensor. 

Diagnosis  is  difficult  in  the  first  case,  easy  in  the  second. 

Prognosis  and  treatment  are  about  the  same  as  for  wounds 

with  osseous  lesions. 

103 


104        LESIONS  OF  THE  ARTICULATIONS 

Penetrating  Wounds  with  Lesions  of  the  Epi- 
physes.— On  cartilage  projectiles  give  rise  to  contusions, 
erosions,  and  abrasions. 

On  the  real  epiphysis  bullets  cause  contusions,  depressions, 
furrows,  grooves,  incomplete  or  cul-de-sac  perforations,  total  perfora- 
tions forming  setons,  either  superficial  or  deep,  and  abrasions. 

The  FURROWS  and  grooves  are  clean,  no  fissures  radiating 
from  them. 

The  INCOMPLETE  PERFORATIONS  have  orifices  and  tracks 
of  smaller  dimensions  than  the  diameter  of  the  bullet. 
Lines  of  fissure  are  rare. 

Total  perforations  are  nearly  always  simple.  When 
they  are  peripheral,  the  compact  outer  wall  of  the  epiphysis 
is  divided  into  subperiosteal  fragments,  which,  when  pressed 
upon,  crepitate. 

The  aperttire  of  entry  is  clean,  and  its  dimensions  are  equal 
to  those  of  the  bullet,  but  are  inferior  or  superior  according 
as  the  velocity  of  the  bullet  was  average,  small,  or  great. 
This  aperture  is  rounded  or  oval,  sometimes  blocked  up  by 
the  periosteum,  which  is  fissured,  but  not  perforated,  where 
it  seems  to  be  punched  out ;  or  sometimes  it  is  masked  by 
the  thick  synovial  membrane  to  such  an  extent  that  the 
aperture  can  no  longer  be  found  on  the  dead  body.  Occa- 
sionally it  is  surrounded  by  minute  splinters  coming  from 
the  external  compact  table. 

The  aperture  of  exit  is  larger ;  it  is  irregular,  lined  by 
splinters,  that  are  few  in  number,  narrow,  triangular,  or 
rectangular,  often  adherent,  opening  like  shutters.  Its 
dimensions  but  little  exceed  those  of  the  bullet  (8  to 
9  millimetres). 

The  track  is  regular,  and  either  cylindrical  or  conical. 
Fissures,  when  they  exist,  are  generally  under  the  cartilage 
or  the  periosteum  ;  they  do  not  gape.  They  may  be  absent, 
or,  on  the  contrary,  be  deep  and  branching.  The  more  the 
tissue  of  the  epiphysis  is  resistant  (trochlea  of  the  humerus, 


PENETRATING   WOUNDS  105 

condyle),  the  more  the  division  is  complete,  the  easier  is 
comminution  of  the  articular  fragments. 

The  track  is  free  of  small  remains  of  splinters. 

Such  are  the  simple  lesions.  In  their  vicinity  complex 
ones  are  found,  but  in  truth  more  rarely.  The  head  of  the 
bone  is  separated  in  the  joint  without  splintering,  divided 
into  fragments,  which  are  more  sedentary  than  propelled  in 
various  directions,  as  they  are  kept  together  by  the  capsule 
and  the  corresponding  articular  surface.  It  is  a  remarkable 
fact  that  in  these  cases  capsular  fragments  and  those  of  the 
soft  parts  are  most  often  not  in  connection  with  the  bony 
traumatism ;  the  capsule  is  preserved,  and  may  even  be 
crossed  in  a  linear  manner.  The  narrowness  of  the  capsular 
lesions  and  the  slight  traumatisms  produced  by  the  present 
bullets  explain  to  a  great  extent  the  favourable  evolution  of 
these  wounds. 

Such  are  the  lesions  seen  on  the  undoubtedly  epiphysial 
portion  of  the  osseous  extremity. 

When  the  bullet  penetrates  at  the  level  of  the  growing 
cartilage,  it  gives  rise  to  lesions  both  of  the  epiphysis  and 
of  the  diaphysis :  a  clear  aperture  of  entry,  an  aperture  of 
exit  with  splinters,  and  long  fissures  that  radiate  in  the 
articulation  and  above  it. 

Again,  we  see  these  same  lesions  when  the  bullet  keeps 
away  from  the  growing  cartilage,  but  then  the  fissures, 
though  in  the  articulation,  do  not  radiate  below  this 
cartilage. 

Finally,  in  real  joint  lesions  the  damage  is  generally  limited, 
the  splinters  and  the  fragments  are  few  in  number,  adherent 
and  kept  in  their  place  by  a  capsule  which  is  but  little 
open ;  solutions  of  continuity  of  the  limb  are  unimportant  and 
rare.  Epiphysial  lesions  are  therefore,  as  to  their  extent 
both  in  length  and  in  breadth,  very  different  from  lesions  of 
the  diaphysis,  and  we  may  often  regard  them  in  the  light 
of  simple  fractures, 


io6        LESIONS  OF  THE  ARTICULATIONS 


Sometimes  we  have  to  deal  with  abrasions. 

The  damage  done  by  large  pieces  of  shell  is  very  different, 
both  as  regards  extent  and  complexity,  but  it  takes  effect 
much  more  often  on  the  soft  parts  than  on  the  articulation 
itself.  When  the  bones  are  implicated,  if  the  joint  is  at  the 
same  time  widely  opened,  we  generally  see  the  same  type 
of  lesion  a,s  with  bullets. 

General  Consideration  of  the  Types  of  Articular 
Fractures  by  Projectiles. — We  have  shown  that  these 
types  are  dominated  by  three  conditions,  the  most  important 


2. 


Fig.  14. 

I.  Epitrochlear-epicondylar  line  following  that  of  the  growth  cartilage. 

2.  Subjacent  lesion,  or  lesion  of  the  growth  cartilage  (limited  lesion). 

3.  Lesion  corresponding  to  the  line  of  the  cartilage  (lesion  of  the 
epiphysial-diaphysial  type).  4.  Superjacent  lesion  to  the  growth 
cartilage  (lesion  of  the  diaphysial  type). 

of  which  are  the  two  first :  the  part  hit,  the  architectural  con- 
stitution of  the  bone,  the  velocity  of  the  bullet  or  the  range 
distance. 

I.  The  Part  Hit. — Bullets  that  reach  the  bone  at  the 
same  point  always  produce  identical  or  analogous  lesions. 
Therefore,  when  we  are  well  up  in  our  pathological 
anatomy,  we  can  affirm  that  such  and  such  a  lesion  exists 
in  a  wounded  man. 

The  important  point  for  us  to  fix  in  an  articulation  is  the 
line  of  the  growing  cartilage.  Beneath  this  is  the  real 
epiphysial  tissue,  more  or  less  spongy,  with  short  trabeculae. 


TYPES  OF  ARTICULAR  FRACTURES         107 

Here  the  bullet  produces  a  special  lesion,  epiphysial.  Above 
this  the  tissue  of  the  epiphysis  and  of  the  diaphysis,  or  of 
thediaphysis  alone,  of  different  constitution,  presents  lesions 
that  are  also  different,  and  offer  the  type  both  of  the  epiphysis 
and  of  the  diaphysis.  Higher  up  towards  the  diaphysis  the 
lesion  is  a  lesion  of  the  diaphysis. 

2.  Architectural  Constitution. — The  spongy  tissue  or  arti- 
cular bulb,  subjacent  to  the  line  of  the  growing  cartilage, 
shows  localized  but  not  radiating  lesions.  The  subjacent 
tissue  becomes  perforated  and  fissured,  and,  as  the  archi- 
tectural fibres  become  shorter  as  we  approach  the  margins 
of  the  bone,  the  fissures  will  be  all  the  shorter  in  pro- 
portion as  the  lesion  will  be  more  peripheral.  For  each 
articulation  the  fissures  take  the  directions  forced  on  them 
by  the  disposition  of  the  architectural  fibres. 

3.  Tlie  Velocity  of  the  Bullet  fixes,  not  the  osseous  type 
or  its  radiations,  but  the  state  of  comminution.  The 
greater  the  velocity,  the  more  in  general  is  the  type  one  of 
comminution.  This  is  specially  remarkable  in  those  lesions 
implicating  the  epiphysis  and  the  diaphysis.  The  diameter 
of  the  bullet  also  plays  a  certain  part.  The  larger  it  is,  the 
velocity  being  equal,  the  more  the  comminution. 

Diagnosis. — When  the  osseous  lesions  are  very  com- 
minuted and  accompanied  by  the  signs  of  grave  fractures 
(change  of  shape  of  the  limb,  abnormal  mobility,  crepita- 
tion), the  diagnosis  is  evident;  but  nearly  always,  with 
limited  lesions  and  slight  reaction,  it  is  less  easy  to  establish. 
Yet  even  in  these  cases  it  is  quite  possible  to  be  certain. 

The  pain  is  not  at  all  characteristic,  functional  impotence 
is  an  uncertain  sign.  Wounded  men  who  have  perfora- 
tions of  the  large  articulations  still  manage  to  move  the 
joints.  Discharge  of  synovia  is  frequently  absent  on  account 
of  the  narrowness  of  the  capsule  wounds. 

The  following  furnish  valuable  indications:  Enlargement 
of  the  aperture  of  exit  in  short  distance  lesions  affecting  the 


io8        LESIONS  OF  THE  ARTICULATIONS 

epiphysis  and  the  diaphysis ;  hone-ditst  found  in  the  track 
or  in  the  secretions  from  the  wound ;  the  very  fine  furrows 
ov  scratches  seen  on  the  bullet  when  it  has  been  arrested  in 
the  limb.  The  clearest  signs  are  derived  from  the  relation 
of  the  external  woimds  to  the  region  occupied  by  the  articulation, 
rapid  hemorrhage,  arthritis,  the  indications  given  by  radio- 
graphy. 

As  modern  bullets  do  not  as  a  rule  deviate  in  going 
through  bony  extremities,  the  position  of  the  apertures  and 
their  relations  to  the  joint  furnish  one  of  the  most  reliable 
signs.  We  may  call  it  pathognomonic  when  the  articula- 
tion is  superficial. 

Not  only  do  these  relations  of  the  track  to  the  joint 
determine  the  general  diagnosis,  but  they  allow  us  also  to 
establish  the  differential  diagnosis  between  a  lesion  of  the 
epiphysis,  one  of  the  epiphysis  and  diaphysis,  and  one  of  the 
diaphysis  alone. 

Radiography  does  not  give  us  in  bony  lesions  of  joints 
the  striking  and  nearly  always  constant  pictures  that  it 
furnishes  in  lesions  of  the  diaphysis.  However,  radiographic 
indications  are  of  great  value.  Lesions  of  the  epiphysis 
and  diaphysis  are  often  found  out  by  this  means,  and  very 
often  an  educated  eye  will  recognize  a  clean  perforation  of 
the  epiphysis  or  a  furrow — that  is  to  say,  the  simplest  lesions. 
More  complex  damage,  such  as  the  presence  of  fragments, 
is  easily  reproduced  by  radiography. 

If,  of  all  the  signs,  the  most  simple,  the  most  practical, 
the  most  valuable,  is  the  one  furnished  by  the  relations  of  the 
wounds  to  the  articulation,  yet  we  must  remember  that,  to  reap 
the  full  advantage  from  it,  we  must  take  into  account  the 
position  the  wounded  man  occupied  at  the  moment  of  the 
traumatism. 

Progress,  Prognosis  — Formerly  wounds  of  the  articula- 
tions were  particularly  serious.  Infection  was  habitual.  After 
a  few  days  of  relative  quiet  the  joint  became  swollen,  painful, 


TYPES  OF  ARTICULAR  FRACTURES         109 

and  tense ;  temperature  rose,  suppuration  supervened,  the 
joint  soon  was  full  of  pus,  which  became  metastatic,  either 
through  mechanical  means  or  through  the  spread  of  infec- 
tion. If  the  case  did  not  come  under  the  care  of  a  prudent 
surgeon,  who  would  decide  to  pursue  the  pus  by  means  of 
large  incisions,  to  secure  free  drainage,  and  to  prevent  its 
return  by  the  use  of  topics,  the  wounded  man  succumbed 
to  purulent  infection. 

Things  have  very  much  changed ;  but  it  must  not  be 
imagined  that  simple  evolution,  often  aseptic,  of  the  joints 
that  have  been  penetrated,  with  slight  reaction  and  trifling 
serous  or  sero-purulent  excretion,  is  to  be  considered  the 
rule  without  any  exceptions.  Prognosis  of  a  bullet  wound 
of  an  articulation  should  always  be  cautious,  therefore  its 
treatment  ought  always  to  be  in  the  hands  of  a  capable 
surgeon. 

Articulations  are  not  exclusively  traversed  by  pointed 
bullets,  that  rarely  carry  infecting  foreign  bodies  with  them ; 
joints  are  also  penetrated  by  deflected  bullets,  shrapnel 
bullets,  shell  fragments.  In  such  cases  we  must  expect  the 
appearance  of  arthritis,  with  which  we  must  contend  by 
employing  appropriate  and  very  active  treatment. 

Treatment. — Conservative  treatment  is  indispensable  in  the 
very  large  majority — we  may  even  say  in  the  sum  total — of 
articular  lesions  produced  by  bullets. 

In  narrow,  non-infected  wounds,  the  result  of  bullets  fired 
point-blank,  we  must  be  satisfied  with  simple  dressing  of  the 
apertures  and  immobilization.  Even  if  there  is  no  bony 
solution  of  continuity,  immobilization  must  be  carried  out. 
We  must  abstain  from  any  exploration.  In  general  there 
are  no  splinters  to  remove. 

In  larger  traumatisms,  produced  by  deflected  bullets, 
shrapnel  bullets,  etc.,  wounds  that  are  often  contaminated, 
the  articulation  should  be  washed  out  (solution  of  carbolic 
acid,  20  per  cent. ;  hydrogen  peroxide  in  small  quantities), 


no        LESIONS  OF  THE  ARTICULATIONS 

after  removal  of  all  constriction  by  incisions ;  the  wound  is 
then  drained.  The  wounded  man  should  be  kept  under 
supervision.  All  transport  is  to  be  avoided,  especially  if 
the  wound  is  seated  in  the  lower  limb  and  in  a  big  joint. 
Shrapnel  bullets  and  shell  fragments  remaining  in  the 
articulation  should  be  removed  as  early  as  possible,  but 
invariably  with  aseptic  precautions. 

Arthritis  that  has  undergone  suppuration  necessitates 
prompt  arthrotomy.  Resection  incisions  should  be  made 
use  of.  It  is  preferable  to  make  double  openings  rather 
than  to  limit  ourselves  to  one  incision.  In  these  cases 
ablation  of  the  free  splinters  is  imperatively  called  for.  If, 
in  spite  of  the  arthrotomy,  of  incisions,  and  of  intermittent 
interarticular  washing  out,  suppuration  persists  in  abundance 
and  in  a  threatening  manner,  we  must  have  recourse  to  an 
atypical  resection,  followed  by  prolonged  immobilization  of 
the  articulation  to  avoid  subsequent  deformity. 

Amputation  will  be  an  extreme  and  exceptional  measure, 
only  to  be  utilized  in  threatening  septicaemic  symptoms. 

Immediate  immohilization  of  the  articulation  is  procured 
by  methods  that  may  be  at  hand  to  treat  fracture  of  the 
diaphysis. 

The  surgeon  will  endeavour  to  obtain  immobilization 
during  regular  treatment  by  apparatus  which  leave  the  articu- 
lation free ;  these  render  easy  the  supervision  of  the  wound 
and  the  application  of  the  dressings,  and  allow  him  to  make 
incisions  which  burrowing  of  the  pus  might  necessitate. 

To  attain  this  immobilization  we  cannot  speak  too  highly 
of  our  hollowed  oitt  gutter  splints  with  valves  that  fulfil  all  these 
conditions. 

As  a  general  rule,  moderate  compression  brought  about 
by  cotton- wool  applied  to  the  joint  is  very  useful  to  pre- 
vent puffiness  of,  or  effusion  into,  the  articulation. 

Passive  movement  must  be  begun  very  early.  Naturally 
the  nature  of  the  lesions  will  here  be  taken  into  considera- 


LESIONS  OF  FLAT  AND  SHORT  BONES     in 

tion.  Generally  this  most  necessary  part  of  the  treatment 
is  not  commenced  soon  enough,  hence  stiffness  of  the  joint 
and  most  regrettable  functional  loss  of  power. 

Lesions  of  the  Flat  Bones  and  of  the  Short  Bones. 

Flat  Bones. — Flat  bones — cranial,  innominate,  scapula 
— when  hit  by  projectiles,  present  contusions,  linear,  radiatedj 
concentric  fissures ,  occurring  either  on  the  side  first  hit,  or  on 
the  opposite  side,  or  even  on  both  sides,  with  or  without 
displacement  of  splinters  from  the  internal  face  of  the 
bone  ;  indentations,  furrows,  and  grooves  which  are  limited  to 
the  track  of  the  projectile,  or  complicated  by  the  presence  of 
more  or  less  depressed  splinters  from  the  internal  table ; 
finally,  both  incomplete  and  complete  perforations. 

The  aperture  of  entry  of  these  perforations  is  nearly 
always  clean  and  regular,  having  dimensions  below  or 
above  the  diametrical  dimensions  of  the  projectile.  The 
track  is  regular.  The  aperture  of  exit  is  a  little  larger, 
surrounded  by  quadrilateral,  triangular,  or  lunated  splinters 
more  or  less  adherent,  varying  in  size  from  a  few  milli- 
metres to  I  or  2  centimetres.  Their  number  varies  from 
two  or  three  to  ten,  even  to  fifteen.  Generally  they  are 
in  small  numbers. 

Direct  fissures  often  unite  by  the  shortest  track  the  two 
orifices  of  a  through-and-through  perforation  ;  there  are 
frequently  concentric  fissures  in  addition.  The  more  com- 
pact the  bone,  the  more  this  spreading  is  seen.  It  is  more 
observed  in  the  cranial  bones  than  in  the  os  innominatum. 
The  lesions  are  generally  circumscribed,  and  complete  frac- 
ture of  a  flat  bone  is  impossible  when  it  has  been  hit 
perpendicularly  to  its  surface.  Under  such  conditions  the 
OS  innominatum  cannot  be  fractured  with  solution  of  con- 
tinuity by  a  bullet. 

Let  us  draw  attention  to  the  furrows  on  the  edges  and  to 
the  abrasions  of  the  apophyses. 


112         LESIONS  OF  THE  ARTICULATIONS 

Bullets  that  reach  the  flat  bones  at  a  tangent  give  rise  to 
losses  of  substance  which  extend  to  the  whole  track,  and 
which  are  prolonged  both  upwards  and  downwards  by- 
numerous  but  adherent  splinters  (scapula).  In  these  cases 
solutions  of  continuity  may  be  seen. 

The  fragments  of  large  projectiles  produce  fissures, 
furrows,  and  extensive  perforations,  even  sometimes  abra- 
sions. 

Short  Bones. — The  short  bones  (wrist,  tarsus,  etc.), 
present  contusions,  furrows,  perforations,  crushing. 

The  orifices  of  the  usual  perforations  are  narrow,  some- 
times without  fissures.  The  fissures  are  generally  short. 
Comminution  and  also  solutions  of  continuity  are  rare. 

Splinters  are  small^  adherent,  and  few  in  number ;  free 
splinters  are  represented  by  a  kind  of  bony  dust.  To  sum 
up,  the  damage  is  limited  and  very  trifling. 


CHAPTER   IX 

GENERAL  COMPLICATIONS  OCCURRING  IN 
WOUNDS    BY  FIREARMS 

Immediate  Phenomena. — We  have  already  spoken  of 
complications  occurring  through  hcemorvhage,  through  trau- 
matisms of  the  nerves,  and  through  foreign  bodies.  We  have 
now  to  consider — pain,  nervous  delirittm,  local  and  general 
sttipor  (shock),  tetamis,  hospital  gangrene,  ordinary  gangrene, 
localized  or  diffuse  infection,  pyamia. 

Pain. — As  a  general  rule  bullet  wounds  give  rise  to  very- 
little  immediate  pain,  even  when  they  involve  nerves.  A 
great  many  men  hardly  feel  they  have  been  wounded 
Pain  does  not  stop  the  soldier's  dash.  We  all  remember 
the  history  of  a  company  whose  men  in  charging  the  enemy 
only  noticed  their  wounds  through  seeing  the  blood  that 
flowed  from  them. 

The  torn  wounds  caused  by  shell  fragments  are  generally 
painful. 

Nervous  Delirium. — This  is  an  erethismic  form  of 
shock.  It  must  not  be  confounded  with  alcoholic  or 
insane  delirium. 

Wounded  men,  either  singly  or  collectively,  are  attacked 
with  violent  agitation,  with  a  kind  of  fury  or  of  rage ;  they 
perform  the  most  extraordinary  movements,  talk  volubly, 
relate  with  great  vivacity  the  incidents  of  the  action  in 
which   they  have   been  engaged^  weep,  develop   excessive 

113  8 


114  COMPLICATIONS  IN  WOUNDS 

affectionate  feelings,  and  at  the  same  time  their  general 
sensibility  is  deadened. 

Reeb,  Poncet,  and  Gross,  at  Strasburg,  and  I  myself 
at  Saint- Quentin,  have  all  observed  veritable  localized 
epidemics  of  this  delirium. 

The  delirium  may  end  in  collapse.  It  has  sometimes  a 
very  harmful  effect  on  the  progress  of  the  wounds. 

Local  and  General  Stupor. — Local  stupor  is  marked  by 
the  insensibility  of  the  wound.  A  wounded  man  can  finish 
the  detachment  of  his  own  limb,  which  is  nearly  separated, 
without  showing  any  pain.  We  have  seen  this  happen 
several  times.  The  temperature  is  lowered,  the  muscles  are 
soft,  flabby,  dry,  not  injected  nor  secreting.  After  some 
days  reaction  is  complete,  or  gangrene  supervenes. 

With  regard  to  this  complication,  which  is  seen  almost 
exclusively  in  wounds  from  large  projectiles  or  their  frag- 
ments, the  pathogeny  is  obscure  ;  lesion  of  the  nerves  here 
probably  plays  an  important  part.  One  fact  is  well 
established,  that  surgical  intervention  undertaken  in  tissues 
affected  with  local  stupor,  and  on  wounded  men  with  general 
stupor,  does  not  show  good  results.  Gangrene  is  a  frequent 
ending  of  local  stupor. 

Treatment  consists  in  employing  generous  stimulation 
both  general  and  local,  in  wrapping  the  wound  in  cotton- 
wool, and  in  the  temporary  rejection  of  antiseptics. 

General  stupor  is  the  result  of  an  abrupt  concussion  com- 
municated to  the  cerebro-spinal  axis  by  a  violent  shock, 
either  direct  or  transmitted  through  a  large  diaphysis,  the 
seat  of  a  grave  fracture  (shell  explosions,  abrasions  of  limbs 
by  bulky  fragments  of  big  projectiles). 

Dulness  of  the  senses  and  intellect ;  the  eyes  fixed  and 
haggard ;  pupils  very  dilated ;  motionless  features ;  the 
body  covered  with  cold  sweat  ;  slow,  sighing,  weak 
breathing ;  from  time  to  time  extensive  inspiratory  and 
expiratory  movements  ;    small,  irregular   pulse  ;  vomiting  ; 


TETANUS  115 

inconticience  both  of  faeces  and  of  urine  ;  lowering  of  the 
temperature  ;  wounds  dry ;  insensibility ;  intellect  often 
retained,  but  showing  dulness ;  coma — such  are  the  clinical 
characteristics  of  general  stupor. 

General  stupor  may  terminate  rapidly  in  death ;  it  may, 
however,  disappear,  or  become  mitigated  in  a  few  hours. 
It  has  been  said  that  any  wotmded  man  in  a  state  of  stupov 
whose  temperature  sinks  below  36°  C.  will  die. 

All  intervention  excepting  ligature  of  bleeding  arteries  is 
contra-indicated.  Chloroform  is  dangerous  (Crimea).  We 
should  have  recourse  to  the  horizontal  position,  to  local 
(heat)  and  general  stimulants,  to  subcutaneous  injections  of 
ether,  of  caffein,  or  of  camphorated  oil. 

Tetanus. — Tetanus,  whose  frequency  is  variable,  though 
it  was  great  in  former  times  (12  per  cent.,  one  in  seventy- 
nine  during  the  wars  of  the  First  Empire),  was  no  longer  met 
with  in  the  Transvaal  War.  In  the  Russo-Japanese  War 
Holbeck  observed  it  once  in  100  wounded  men.  In  more 
than  4,000  patients  in  this  war  we  only  saw  three  or  four 
cases.     The  number,  however,  is  rapidly  increasing. 

Narrow  wounds,  especially  those  of  the  lower  limbs, 
contaminated  by  the  soil,  infected  by  pieces  of  clothing, 
exposed  to  the  risks  of  suppuration,  exposure  of  the  soldier 
to  cold,  all  predispose  to  tetanus.  In  theory,  tetanus  can  be 
contagious,  but  practically  it  is  not. 

It  may  appear  a  few  moments  or  some  hours  after  the 
wound,  generally  from  the  sixth  to  the  eighth  day,  occasion- 
ally later. 

Its  superacute  form  is  mortal  in  a  few  days  ;  in  its 
chronic  or  slight  forms  cure  is  possible  (31  per  cent.). 

Let  us  rapidly  recall  its  symptomatology:  pain,  spasms 
on  a  level  with  the  wound  (four-fifths  of  the  cases),  then 
very  soon  trismus,  stiffness  of  the  nape  of  the  neck, 
dysphagia,  risus  sardonicus,  muscular  contractions  coming 
on  in  fits,  and  set  up  by  the  slightest  excitement ;    remis- 


ii6  COMPLICATIONS  IN  WOUNDS 

sions  alternating  with  the  crises ;  atypical  fever ;  intelli- 
gence remains  intact. 

Facial  contraction  and  paralysis  in  cephalic  tetanus 
(wounds  of  the  head).  In  the  grave  form,  with  its  rapid 
appearance  (fifth  day),  we  see  the  same  beginning,  the  same 
crises,  but  they  are  longer  and  more  violent.  The  tempera- 
ture is  raised. 

The  treatment  consists,  with  the  idea  of  prevention,  of 
relieving  all  constriction  by  incisions,  of  removal  of  foreign 
bodies  (shrapnel  bullets  and  fragments  of  shell),  of  rapid 
draining  of  the  infected  wounds,  of  disinfection  with 
hydrogen  peroxide,  iodine,  and  solutions  of  carbolic  acid. 
The  conditions  under  which  the  first-aid  stations  work  on 
the  field  of  battle  render  very  difficult  and  eventual  any 
general  employment  of  antitetanic  serum,  even  for  its 
upholders.  Isolation  is  to  be  recommended  in  order  to 
insure  tranquillity  and  to  avoid  disturbing  the  other  patients, 
rather  than  as  a  preventive  measure. 

Against  confirmed  tetanus :  free  incisions,  washing  out 
with  antiseptics,  more  especially  with  hydrogen  peroxide, 
removal  of  foreign  bodies,  rest,  opium,  chloral  and  bromide 
of  potassium  in  large  doses,  sudorifics,  very  much  prolonged 
baths.  Subcutaneous  or  spinal  antitetanic  serotherapy 
has  not  given  any  convincing  results.  Spinal  injections 
of  from  2  to  6  c.c.  of  a  solution  of  sulphate  of  magnesium, 
25  in  100  every  day  during  five  or  six  days,  are 
sedative.  They  act  specially  in  relieving  painful  contrac- 
tions. It  has  been  advised  to  combine  these  injections 
with  others  of  serum  in  large  doses. 

Hospital  Gangrene.- -This  complication,  formerly  fre- 
quent, has  nowadays  almost  disappeared.  It  is  very  con- 
tagious, epidemic,  and  caused  by  Vincent's  bacillus  ;  it  may 
invade  any  wound,  recent  or  old. 

In  the  slight  form,  a  veritable  diphtheria  of  wounds,  it 
shows   itself   by    the   development,    on    unhealthy   looking 


HOSPITAL  GANGRENE  117 

fleshy^  granulations,  of  a  grey  opaline  membrane,  or  a  dry 
bufFy  coat,  analogous  to  the  coating  produced  on  a  wound  by 
the  employment  of  iodoform.  Violent  pain,  spreading  and 
phagedenic  advance  of  the  malady.     No  fever. 

In  the  grave,  pulpy  form,  there  is  seen  a  thick,  putrid, 
pultaceous  buffy  coat,  having  the  colour  of  putty.  Very 
violent  pain,  with  fever  and  solid  oedema.  Abundant  foetid 
ichorous  secretion,  superacute  phagedena.  In  1870  we 
sometimes  saw  the  gluteal  region  and  the  popliteal  region 
become  sphacelated  in  a  few  hours. 

Formerly  the  prognosis  was  very  serious.  In  the  slight 
form,  touching  with  lemon-juice,  with  iodine  (Italy,  1870- 
71  war),  immersions  in  permanganate  of  potassium  solution, 
I  in  1,000,  dressings  with  hydrogen  peroxide  and  with 
Labarraque's  liquid. 

In  the  grave  form,  touching  with  perchloride  of  iron ; 
this  is  very  painful,  but  very  efficacious.  Actual  cautery  on 
the  surface. 

Rapid  and  absolute  isolation  of  the  patient,  to  whom  a 
special  staff  should  be  attached  and  told  off. 

Suppuration,  Phlegmon. — Abundant  suppuration  is 
very  frequent  after  wounds  caused  by  deflected  bullets,  by 
shrapnel  bullets,  or  shell  fragments,  and  wounds  complicated 
by  pieces  of  clothing.  Therefore  we  should  always  care- 
fully examine  the  clothing,  and  look  for  any  loss  of  substance 
at  the  apertures  of  entry,  and  more  especially  in  the  fractures 
themselves. 

When  there  is  extensive  loss  of  substance  in  the  clothing, 
it  is  prudent,  as  a  preventive  measure,  to  relieve  all  con- 
striction at  the  orifice  of  the  wound,  and,  still  better,  to 
immediately  search  for  the  projectile,  which  very  often 
would  tend  to  prevent  the  exit  of  the  pieces  of  clothing,  the 
primary  sources  of  the  infection. 

On  the  advent  of  suppuration  we  should  make  incisions ; 
the  focus  should  be  cleaned  out  with  hot  water,  the  wall  of 


ii8  COMPLICATIONS  IN  WOUNDS 

the  abscess  touched  with  iodine  or  permanganate  of  potas- 
sium (i  in  i,ooo).  Washing  out  should  be  done  with  a 
strong  solution  of  carbolic  acid  (5  per  cent.),  or  with 
hydrogen  peroxide.  The  latter  is  excellent.  It  is  not 
irritating,  and  cleanses  all  cavities  (30  to  50  c.c.  each  time). 
Permanganate  and  hydrogen  peroxide  should  always  he  made  use 
of  in  wounds  that  have  been  soiled  by  earth. 

Hydrogen  peroxide,  whilst  being  the  specific  topic  for 
emphysematous  gangrene,  is  besides  indicated  as  an  anti- 
septic in  the  treatment  of  streptococcal  (phlegmon,  lymphan- 
gitis, erysipelas)  and  putrid  infections. 

Surg'ical  Erysipelas. — It  was  formerly  very  frequent. 
It  was  seen  during  the  Secession  War  (0*4  per  cent.),  in  the 
Russo-Turkish  Campaign  (0*9  per  cent.),  rarely  in  the 
Manchurian  War,  often  in  the  Thrace  Campaign.  Appli- 
cation of  too  irritating  dressings,  occlusion  of  w^ounds  by 
plugging,  both  tend  to  encourage  its  appearance.  Vexatious 
explorations  open  up  a  passage  to  streptococci. 

The  wound  becomes  dry  during  the  progress  of  the 
lymphangitis.  There  is  fever,  and  the  general  condition 
is  bad.  Diffuse  abscesses,  secondary  haemorrhage,  and 
sphacelus,  are  among  the  consequences. 

Gentle,  moist,  boric  acid  dressing,  with  iodine  painting 
(Ferraton) ;  quinine,  alcohol,  as  internal  treatment.  Serum 
treatment  is  but  little  utilized ;  it  may  give  rise  to  accidents. 
Isolation  is  important. 

In  cases  of  lymphangitis  and  of  erysipelas,  Souligoux 
first  washes  the  limb,  then  rubs  it  with  a  soft  brush,  removes 
the  soap  with  alcohol,  and  finally  applies  a  dressing  of 
cotton-wool  soaked  in  ether,  which  is  changed  when  neces- 
sary.    He  has  nothing  but  praise  for  this  treatment. 

Pyaemia. — This  is  rare.  We  have  already  observed 
some  cases  of  it  during  the  present  war  following  wounds  by 
shell  fragments. 

I.  In  a  SLIGHT  form  the  wound  is  painful;  some  fever  may 


PYEMIA  119 

be  noticed  with  sordes,  also  headache  and  depression.     It 
lasts  from  eight  to  fifteen  days  (Ferraton). 

2.  Septicemic  Fever  (Ferraton). — Remittent  fever  with- 
out rigors  (38*39°  C),  gastric  troubles,  dry  tongue,  dried-up 
wound,  bad  general  condition,  rapid  and  small  pulse,  frequent 
respiration,  scanty  and  albuminous  urine,  nervous  disturb- 
ances, both  ataxic  and  adynamic,  that  in  severe  cases  lead 
to  death. 

3.  Pyemia. — Its  appearance  is  encouraged  by  primary 
infection  of  the  wounds  (shrapnel,  shell  fragments),  also 
by  defective  dressing,  delay  in  opening  collections  of  pus, 
tardy  evacuation  ;  intermittent  fever,  with  great  oscillations 
(39°  to  40°  C),  with  severe  rigors,  foetid  secretion  from  the 
wound,  which  is  covered  with  exudation  ;  signs  of  phlebitis ; 
serious  general  condition,  cadaverous  appearance,  dry 
tongue,  diarrhoea,  dyspnoea,  muttering  delirium  (Ferraton). 

Metastatic  abscesses,  both  articular  and  parenchymatous. 
Preventive   Treatment. — Regular  dressings,  immediate  re- 
lieving   of   constrictions,   disinfection  of   the  wounds,  and 
dressing  only  at  long  or  relatively  long  intervals. 

Crowding  should  be  avoided,  and  isolation  of  those  men 
already  infected  must  be  insisted  upon. 

When  pyaemia  is  recognized  as  being  present,  antiseptic 
baths,  washing  out  with  solutions  of  carbolic  acid  or  per- 
manganate, or  with  hydrogen  peroxide,  touching  with  the 
chlorides.  Tonics  should  be  given,  especially  quinine  in 
large  doses  (A.  Guerin)— 8  decigrammes,  i  gramme,  1-50 
grammes  per  day  (12  grains,  i^^  grains,  23  grains).  Injec- 
tions of  nucleinate  of  sodium,  fixation  abscess,  lavage  of  the 
blood. 

Amputation  is  sometimes  necessary,  but  it  is  always  a 
proceeding  of  much  gravity. 

Emphysematous  Gangrene.— Of  great  frequency  in 
wars,  especially  at  the  commencement.  It  has  already  been 
seen  in  many  forms,  chiefly  on  German  wounded  who  have 


I20  COMPLICATIONS  IN   WOUNDS 

been  abandoned.  Surgeons  should  always  be  on  the  look- 
out for  its  appearance,  because  its  progress  is  very  rapid ; 
also  it  necessitates  very  active  treatment,  and  because  of  its 
dangers  of  contagion. 

No  wound  is  safe  from  it,  but  the  wounds  most  exposed 
to  it  are  those  of  shell  fragments  and  of  dangerous  fractures. 

Two  forms  are  described — one  makes  rapid  progress,  but 
is  not  ftdminating ;  the  other  is  absolutely  fulminating.  In 
both  varieties  the  same  general  symptoms  are  seen  ;  the 
progress  alone  is  different. 

The  symptoms  are  pain,  emphysematous  swelling  of  the 
region,  general  disturbance.  The  pain  is  constant ;  it  is  felt 
some  hours  before  the  swelling  and  the  general  disturbance, 
therefore  it  need  not  be  taken  into  too  great  consideration. 

It  is  acute,  violent,  excessive,  constringent.  Nearly  all  the 
patients  ascribe  it  to  the  constriction  of  the  apparatus  or 
of  the  dressings,  but  if  these  are  taken  off  it  is  found  that 
swelling  may  not  as  yet  exist. 

This  pain  depresses  and  lowers  the  wounded  man.  It 
gives  him  the  look  of  a  person  suffering  from  typhus  or 
from  cholera  (sunken  eyes,  earthy  complexion,  etc.). 

The  oedematous  swelling  is  hard,  tense,  white,  then  bronzed, 
showing  brownish  venous  ramifications ;  phlyctense  are 
seen  in  the  vicinity  of  the  wound,  which  has  become  dry. 
The  swelling  is  crepitant.  The  development  of  gas  is  not 
only  perceptible  to  the  fingers,  very  often  it  can  be  heard. 
In  a  few  hours  the  whole  of  a  limb  in  fulminating  cases 
may  be  invaded. 

Sensibility  in  the  affected  limb  is  lost  ;  the  temperature  is 
of  average  intensity  (38°  to  39°C.),  or  else  is  very  high  (40°  C), 
occasionally  it  is  low  (36°  C.) ;  rapid  pulse ;  sighing  respira- 
tion. The  patient  is  perfectly  indifferent  to  all  that  goes  on 
around  him,  and  dies  quietly,  sometimes  suddenly.  Such 
is  the  ordinary  course  of  fulminating  gangrene,  but  the 
description  is  not  unique.     In  some  cases  general  symptoms 


EMPHYSEMATOUS  GANGRENE  121 

predominate  at  first,  on  some  occasions  they  are  mitigated ; 
sometimes  the  emphysema  is  a  long  time  appearing,  and 
remains  localized  for  a  certain  period.  This  is  a  fortunate 
circumstance. 

Very  marked  general  symptoms,  violent  pain,  rapid  gaseous 
development,  are  not  found  in  gangrene  by  compression.  In 
gangrene  by  contusion,  gaseous  development  is  again  found, 
but  it  is  less  rapid,  and  such  well-marked  general  pheno- 
mena are  not  seen. 

Emphysematous  gangrene  commences  in  the  wound ;  gangrene 
by  contusion  commences  at  the  terminal  extremity  of  the  limb. 
Gangrene  through  lesion  of  the  vessels,  when  it  gives  rise  to 
gaseous  development,  shows  the  same  invading  progress, 
but  this,  again,  commences  at  the  terminal  extremity  of  the 
limb. 

The  gaseous  development  is  not  always  due  to  a  septic 
vibrio.  Emphysematous  gangrene,  if  we  take  into  account 
the  prodromal  period,  shows  itself  before  the  suppuration  of  the 
wound  (Trifaud). 

Preventive  Treatments — Strict  disinfection  of  soiled  wounds, 
isolation  of  the  affected  patients,  severe  precautions  with 
regard  to  special  preservation  (amputated  limbs  talcen  away 
at  once,  all  soiled  linen,  dressings,  etc.,  destroyed,  instru- 
ments disinfected  by  flame  or  by  boiling),  to  avoid  contagion. 

In  cases  of  acknowledged  emphysematous  gangrene  we 
should  employ  at  first  free  incisions  of  the  wound,  followed 
by  extensive  washing  out  with  hydrogen  peroxide.  If 
permanganate  of  potassium,  4  in  1,000,  be  associated  with 
the  hydrogen  peroxide,  a  much  more  intense  liberation  of 
oxygen  is  obtained.  At  the  same  time  intracellular  injections 
should  be  utilized. 

Against  the  fulminating  processus  we  should  oppose  a 
barrier  of  hydrogen  peroxide  administered  in  hypodermic 
injections  at  the  point  where  the  cedema  and  the  gaseous 
crepitation    is   arrested.     The   injections   will   be   renewed 


122  COMPLICATIONS  IN  WOUNDS 

morning  and  evening,  or  several  times  during  the  day. 
With  Pravaz's  or  Dieulafoy's  needle  a  double  circle  of 
injections  should  be  made.  Hydrogen  peroxide  is  injected 
by  half  Pravaz  syringefuls,  20  or  30  for  the  leg,  30  or  40  for 
the  thigh,  and  these  injections  are  renewed. 

If  one  is  out  of  hydrogen  peroxide,  oxygen  under  pressure 
can  be  used,  which  can  be  introduced  into  the  limb  by 
insufflation  through  a  Dieulafoy's  needle  that  communicates 
with  a  reservoir  through  an  india-rubber  tube. 

At  various  distances  tension  should  be  relieved  by  in- 
cisions made  in  the  aponeurotic  partitions,  so  as  to  prevent 
the  excessive  tension  of  the  tissues  dilated  by  the  gas ;  this, 
if  left  unrelieved,  will  lead  to  compression  of  the  vessels. 

The  whole  treatment  should  be  carried  out  with  con- 
viction. 

Quick  amputation,  or  rapid  disarticulation  in  healthy 
tissues,  are  the  last  resources  after  failure  of  injections  of 
hydrogen  peroxide.     Circular  section.     No  sutures. 

Alcohol,  quinine,  camphorated  oil. 


CHAPTER  X 

WOUNDS    BY    LARGE    PROJECTILES    AND 
THEIR  FRAGMENTS 

If  small  shell  fragments  produce  lesions  more  or  less 
analogous  to  those  of  bullets,  it  is  not  at  all  the  same  thing 
with  large  fragments  nor  exceptionally  with  the  entire  pro- 
jectile. In  the  soft  parts  these  wounds  show  extensive  and 
deep  contusions,  crushing,  contused  lesions,  tearing  away  of  tissues. 

The  contusions  are  of  all  degrees.  In  their  highest  degree 
of  severity  they  are  marked  by  extensive  effusion  of  blood 
or  of  serum.  When  they  take  effect  on  the  splanchnic 
organs,  which  themselves,  however,  have  apparently  not 
been  touched  by  the  projectile,  we  see  deep  and  extensive 
attritions  which  formerly  were  attributed  to  the  wind  of  the 
projectile. 

The  contused  wounds  are  vast  erosions,  big  furrows,  large 
lesions  forming  a  cul-de-sac,  wounds  with  large  pieces  of 
tissue  hanging  from  them,  fimbriated,  ecchymotic,  contused 
in  their  depths;  they  are  abrasions  with  torn  surfaces  and 
quivering  and  herniated  muscles.  Very  frequently  the 
wounds  in  their  deep  parts  are  complicated  by  metallic 
foreign  bodies,  by  earth,  by  fragments  of  clothing.  We 
have  good  reason  to  be  surprised  at  the  enormous  size  of 
some  of  the  foreign  bodies  that  are  extracted.  Otis  speaks 
of  a  i2-pound  shell  lodged  in  the  gluteal  region;  Constan 
of  a  shell  fragment  weighing  850  grammes  lodged  in  the 

123 


124         WOUNDS  BY  LARGE  PROJECTILES 

thigh,  into  which  it  had  penetrated  through  an  opening  only 
4  centimetres  in  length. 

Occasionally  we  observe  widely  gaping  setons. 

Large  and  average  sized  fragments  of  arnwitr -piercing 
shells  give  rise  to  large  slits,  partial  or  total  abrasions  of 
the  limbs ;  very  different  to  the  tearing  away  and  crushing 
contusions  brought  about  by  large  fragments  of  other 
shells.  The  cul-de-sac  wounds  of  these  armour-piercing 
shells  are  rarely  deep ;  they  are  often  complicated  by  pieces 
of  clothing.  Generally  the  orifice  is  clean.  We  still  see 
total  perforations  with  an  irregular,  big  aperture  of  exit 
whose  lips  are  everted. 

By  the  side  of  these  excessive  disturbances  let  us  re- 
member, as  a  sort  of  antithesis,  the  ingraining  of  the 
integument,  the  small  wounds,  often  very  numerous,  pro 
duced  by  the  metallic  dust  of  melinite  shell,  the  cul-de-sac 
wounds  with  a  very  small  orifice  that  harbour  small  shell- 
fragments  at  a  depth  varying  from  a  few  to  15  centimetres. 

To  return  to  the  large  fragments.  Their  contused 
wounds,  often  complicated  by  local  numbness,  foreign 
bodies,  both  metallic  and  derived  from  the  clothing,  bleed 
very  slightly,  but  are  doomed  to  suppuration,  and  threatened 
by  grave  complications  (gangrene,  tetanus). 

Treatment. — Large  traumatisms  occurring  in  labouring 
men  enable  us  in  everyday  practice  to  foresee  the  extreme 
limit  to  which  we  can  push  conservatism  in  the  cases  of 
soldiers  wounded  by  big  shell  fragments. 

In  their  treatment  it  has  been  proposed  to  utilize  the 
method  called  "  Reclus's  packing."  The  following  is  the 
way  in  which  it  is  applied : 

The  patient's  state  of  prostration  having  been  relieved 
by  injections  of  normal  saline,  of  caffeine,  of  ether,  the 
wound  itself  and  its  diverticula  are  disinfected  by  a 
current  of  water  at  60°  C,  which  is  at  the  same  time 
antiseptic  and  haemostatic.     Clots  of  blood,  free  splinters, 


TREATMENT  125 

and  all  tissue  that  has  lost  its  vitality,  are  removed ;  the 
wound  surface  is  wiped  with  a  pad,  which  is  soaked  in  a 
solution  of  permanganate  of  potassium ;  then  we  apply  an 
ointment  containing  corrosive  sublimate,  salol,  antipyrine, 
carbolic  acid,  iodoform,  with  vaseline  for  excipient. 

The  ointment  should  be  covered  with  a  thick  layer  of 
hydrophile  cotton-wool  and  a  muslin  bandage. 

To  this  local  treatment  Reclus  added  injections  of  normal 
saline  with  a  dessertspoonful  of  brandy,  injections  of 
caffeine,  etc. ;  a  long  interval  should  elapse  before  a  change 
of  dressing ;  it  is  removed  in  about  the  third  week. 

Irrigation  with  hot  water  has  been  retained,  but  the 
antiseptic  packing  has  been  replaced,  after  antiseptic  wash- 
ing with  hydrogen  peroxide,  by  a  dressing,  only  changed  at 
long  intervals. 

We  do  not  think  that  this  dressing  with  long  intervals, 
after  one  or  two  cleansings  with  antiseptics,  is  preferable  to 
the  use  of  topics  with  a  more  persistent  action. 

If  Reclus's  dressing  is  considered  complicated,  we  need 
only  simplify  it,  but  its  general  idea — (i)  dressing  rarely 
changed,  (2)  use  of  topical  remedies  with  a  persistent  action 
— should  be  maintained.  The  treatment  is  not  new ;  it 
forms  part  of  our  old  and  good  traditions. 

In  1870-71  we  saw  used  for  wounds  rarely  changed 
dressings  of  powdered  charcoal,  mixed  with  powder  of 
cinchona  and  of  camphor ;  later  still,  Lucas-Championniere 
advised  in  these  cases  the  employment  of  antiseptic  powders 
with  a  lasting  action. 

All  these  are  treatments  to  be  recommended. 


CHAPTER  XI 
AMPUTATION 

Indications. — hmnediate  amputation  is,  so  to  speak,  never 
indicated  in  traumatisms  through  bullets. 

It  is  only  admissible  in  cases  of  confirmed  gangrene. 

In  the  most  comminuted  fractures,  neither  very  extensive 
damage  of  the  soft  parts,  nor  an  extreme  condition  of 
comminution  of  the  diaphyses,  nor  supposed  nor  evident 
lesions  of  the  large  vessels,  nor  injury  to  important  nerves, 
can  be  looked  upon  as  indications  for  amputation. 

Very  great  disturbances  of  the  soft  parts  can  be  repaired ; 
it  is  possible  to  obtain  union  in  the  bones,  even  when  a 
fracture  is  comminuted ;  lesions  of  the  large  vessels  are  not 
always  followed  by  gangrene,  and  we  cannot  be  absolutely 
precise  in  laying  down  the  exact  nature  of  wounds  of 
important  nerves  by  bullets. 

Immediate  and  atypical  amputation  can  only  be  called  for  in 
cases  of  complete  smashing  or  of  almost  total  tearing  off  of  a  limb 
by  a  big  projectile  or  by  a  big  fragment. 

Later  on,  amputation  may  be  necessitated  by — 

1.  Confirmed  trau?natic  gangrene. 

2.  Rapid  extension  of  emphysematous  gangrene^  which  is 
almost  generalized  in  one  limb. 

3.  Conditionally,  by  an  enormous  diffuse  aneurysm,  which 
threatens  to  rupture  if  the  surgeon  does  not  feel  himself 
qualified  to  put  on  a  direct  ligature. 

4.  By  very  grave  complications  through  suppuration,  especially 
osteomyelitis. 

126 


INDICATIONS  127 

Amputation  must  not  be  carried  out  during  the  period  of 
shock,  by  reason  of  its  extreme  gravity. 

It  should  be  carried  out  as  soon  as  the  indications  for  its 
performance  are  absolutely  confirmed.  The  incisions  should 
be  made  as  low  as  possible. 

Disarticulation  is  preferable  to  amputation  when  removal 
of  the  limb  is  rendered  necessary  by  medullary  lesions. 

The  circular  method  in  cases  of  gangrene ;  in  other  cases 
the  circular  method  and  the  method  with  square  flaps 
should  be  preferred. 

When  there  is  danger  of  infection  of  the  stump,  the 
wound  should  be  left  open. 


CHAPTER  XII 
WOUNDS   OF   THE   SKULL   AND    BRAIN 

Injuries  of  the  skull  and  brain  occur  very  frequently. 
Their  proportion  is  commonly  said  to  be  from  12  to  15  per 
cent,  of  the  total  number  of  injuries.  More  than  half  of  the 
wounded  succumb  on  the  battlefield. 

With  the  firing-line  in  sheltered  trenches,  these  injuries 
increase  in  number  ;  but  the  total  of  cases  seen  at  the 
ambulances  remains  about  the  same.  Soldiers  who  receive 
these  kinds  of  wounds  rapidly  succumb.    . 

Injuries  of  the  Scalp. 

The  soft  tissues  (the  scalp)  covering  the  skull  are  bruised 
by  bullets,  furrowed,  perforated  as  if  by  a  seton,  on  the 
lateral  parts.  Shell  fragments  divide,  perforate,  or  lacerate 
them  often  to  a  great  extent  ;  sometimes  it  seems  as  if  the 
wounded  men  had  been  scalped.  Cold  steel  weapons  may 
cut  through  the  scalp  in  many  places.  Slightly  compressive 
aseptic  or  antiseptic  dressings  will  generally  suffice  to  secure 
their  healing.     Their  evolution  is  simple. 

Wounds  of  the  Skull  and  Brain. 

When  the  skull  is  struck  by  a  bullet,  contusions,  cracks, 
and  fissiives,  depressions,  slight  grazings,  grooves,  single  perfora- 
tions, double  or  throiigh-and-through  perforations  are  observed. 

128 


WoVnds  of  the  skull  And  brain   129 

Cqi^'TusioNS,  Fissures,  Fractures  of  the  Inner  Table, 
ETC. — Confusions  are  the  results  of  tangential  shock  or  of 
direct  shock  (low  velocity).  Sometimes  they  may  be  re- 
cognized by  denudation  of  the  bone  j  at  other  times  they 
may  only  be  suspected. 

Cracks  and  Jissttres  involve  both  tables  of  the  skull  of  orie 
table  only.  Those  of  the  outer  table  are  exceptionally  met 
with  (Delorme).  Fissures  of  the  inner  table  are  linear, 
curved,  circular-,  oval-,  radiant-,  X-  or  T-shaped,  and  are 
accompanied  by  slight  loosening  of  the  dura  mater.  In 
general,  in  fissures  of  both  tables,  the  fragments  of  the 
inner  table  are  depressed.  The  diagnosis  is  effected  by  de 
visu  verification  of  the  fissures  on  the  outer  table.  When 
we  find  these  last,  we  may  conclude  that  the  inner  table 
presents  the  same  kind  of  lesion,  but  in  a  more  serious  form. 

Depressions  due  to  bullets  are  only  exceptional. 

Grooves  and  Furrows. — Grooves  and  furrows  occur 
frequently.  In  the  least  serious  form  they  consist  of  super- 
ficial, canalicular  abrasions,  with  very  regular  borders  of 
the  outer  table  or  of  the  outer  table  and  the  diploe.  These 
grooves  specially  extend  over  the  comparatively  fiat  surfaces 
of  the  skull. 

Even  when  the  lesion  on  the  outer  table  appears  of  the 
most  simple  nature,  it  is  in  most  cases  complicated  with 
splintered  fragments  of  the  inner  table  ;  these  are  free  and 
pressed  down  on  to  the  dura  mater  or  on  to  the  brain. 

It  is  not  impossible  for  the  inner  table  to  remain 
absolutely  intact,  as  we  have  just  seen  in  two  cases  in 
which  it  appeared  very  distinctly,  uniformly  smooth  in 
appearance,  at  the  bottom  of  the  groove.  When  the  groove 
includes  the  whole  thickness  of  the  bony  wall^  the  resulting 
small  splintered  fragments  are  as  a  rule  propelled  rather 
towards  the  aperture  of  exit  than  towards  the  meninges  and 
the  brain. 

Single  Perforations. — -Single  perforations,  or  perfora- 

9 


I30     WOUNDS  OF  THE  SKULL  AND  BRAIN 

tions  of  one  wall  only,  are  comparatively  rare ;  they 
especially  occur  when  the  projectile  is  fired  point-blank 
from  a  long  distance,  or  when  the  bullet  has  ricochetted. 
The  aperture  of  entry  is  like  a  punched-out  opening, 
circular  or  oval,  its  diameter  being  a  little  less  than  that  of 
the  projectile,  with  somewhat  greater  loss  of  substance 
towards  the  inner  table.  The  bevelled  surface  of  the  inner 
table  has  supphed  the  few  free  or  still  adherent  splinters, 
which  have  scarcely  left  the  periphery  of  the  gap  in  the  bone. 

Contusion  of  the  nervous  substance  is  less  pronounced 
in  the  intracerebral  track  than  in  through-and-through 
perforations.  The  tunnelled  cerebral  wound  hardly  ever 
contains  splinters  ;  but  if  it  does,  they  are  small.  The 
organic  fragments,  or  the  shreds  of  clothing  that  may  be 
swept  along,  are  small  or  absent ;  the  bullet  itself  has  lodged 
in  some  part  of  the  cerebral  substance. 

In  some  instances  the  bullet  becomes  fixed  against  the 
internal  part  of  the  skull,  at  a  point  symmetrically  opposite 
to  the  wound  of  entrance,  bruising  the  bone,  fissuring  it  on 
its  outer  table,  or  on  both  of  its  tables,  or  even  limiting 
the  focus  of  large  splinters  that  prepared  its  exit. 

Double  Perforations. — Double  or  through-and-through 
perforations  are  the  most  common  cranial  lesions  resulting 
from  modern  bullets,  but  they  are  seldom  observed  in  the 
rear.  They  present  circular-  or  oval-shaped  apertures  of 
entry  like  those  of  perforations  of  one  wall — i.e.,  bevelled  at 
the  expense  of  the  inner  table.  As  for  the  aperture  of  exit, 
on  the  table  the  bullet  first  passes  through — ^.^.,  on  the  inner 
table — it  is  circular,  regular  in  shape,  cut  as  with  a  punch, 
and,  on  the  outer  table,  the  last  one  perforated,  it  is  enlarged, 
bevelled,  splintered,  the  splinters  being  adherent  or  loose. 
There  is  contusion  of  the  intracerebral  track  for  a  short 
distance,  or  for  a  distance  of  several  centimetres  from  it, 
according  to  the  velocity  of  the  bullet.  The  track  contains 
loose  splinters,  disseminated  in  the  cerebral  substance,  if  the 


WOUNDS  OF  THE  SKULL  AND  BRAIN      131 

wound  had  been  received  at  long  range  with  low  velocity ; 
in  the  opposite  case  the  free  splinters  are  driven  forward. 
At  the  aperture  of  entry  the  dura  mater  is  torn  and  loosened ; 
at  the  exit  it  is  perforated,  but  not  loosened. 

When  the  velocity  of  the  bullet  is  excessive,  the  whole 
cerebral  substance  may  be  dilacerated,  and  the  radiated  fissures, 
which  were  very  limited  when  caused  by  long-range  firing, 
are  here  very  much  increased  in  number  and  in  extent. 
The  aperture  of  exit  is  large,  and  from  it  flows  a  diffluent 
cerebral  mass.  This  may  be  called  the  explosive  lesion  of 
firearms.  With  double  perforations,  survival  is  only  possible 
when  the  firing  has  been  from  a  long  range,  and  the  velocity 
of  the  bullet  has  been  low. 

Tangential  Perforations. — This  is  a  variety  of  cranial 
traumatism  of  which  recent  wars  have  shown  the  relative 
frequency.  They  are  perforations  the  orifices  of  which  are 
oblique  and  near  together,  preceded  by  a  groove  and  joined 
together  by  numerous  fissures,  which  form  the  limits  of 
short  and  generally  adherent  splinters.  The  bullet  has 
thrown  off  in  its  course  a  few  free  splinters,  shreds  of  hair, 
and  sometimes  particles  of  headgear.  The  cerebral  dilacera- 
tion  is  more  superficial,  less  severe  than  in  other  perfora- 
tions. Consequently  these  wounded  are  quite  likely  to 
recover.  They,  together  with  those  suffering  from  grooves, 
present  the  most  favourable  cases,  and  also  the  ones  that 
more  particularly  require  surgical  intervention. 

Fissures  complicating  tangential  perforations  are  more  or 
less  extensive  and  numerous  ;  they  are  circular,  linear,  or 
radiant,  often  uniting  both  apertures. 

Injuries  from  Large  Projectiles. — Shrapnel  bullets 
inflict  injuries  similar  to  those  produced  by  rifle  bullets. 
Contacts  and  single  perforations  are  with  them  more 
frequent  than  double  perforations.  Grooves  are  very  rare. 
The  orifices  of  the  perforations  are  a  little  larger  than  those 
of  rifle  bullets. 


132     WOUNDS  OF  THE  SKULL  AND  BRAtN 

Large  fragments  of  shells  produce  contusions,  fissures, 
depressions,  and  especially  dilacerations. 

If  the  general  features  of  cranial  orifices  are,  so  to  speak, 
always  the  same,  there  is  reason,  from  the  point  of  view  of 
symptomatology,  as  from  that  of  prognosis,  to  distinguish 
the  through-and-through  perforations  according  to  their 
location.  We  have  sketched  several  groups  of  them  that 
ought  to  be  kept  in  view  and  better  studied :  the  antero- 
posterior or  postero-anterior  perforations,  fronto-occipital,  fronto- 
temporal,  fronto-parietal,  parieto-occipital ;  bilateral,  bitem- 
poral, biparietal,  bioccipital ;  the  perforations  that  follow 
along  a  vertical  or  oblique  plane,  a  line  from  the  vault  to  the 
base,  or  vice  versa. 

Diagnosis. — The  diagnosis  of  open  cranio-encephalic 
wounds  inflicted  by  projectiles  is  generally  easy.  Discharge 
of  cerebrospinal  fluid,  loss  of  cranial  tissue — perceptible  to  the 
finger,  sometimes  visible — issue  of  cerebral  material  from  the 
aperture  of  exit,  or  from  the  aperture  of  entry,  the  direction  followed 
by  the  missile,  cerebral  distnrbajices  of  deficit  or  of  meningo- 
encephalic  excitement,  are  the  general  characteristics  of 
through-and-through  perforations,  of  single  perforations,  of 
grooves  involving  the  whole  thickness  of  the  bones  of  the 
skull,  accompanied  by  laceration  of  the  dura  mater. 

Shallow  grooves  are  recognized  by  an  extensive  cranial 
depression  with  sharp  edges. 

Pain,  at  first  evoked  by  pressure  of  the  finger  along  the 
fissures,  and  pericranial  swelling  denote  the  pressure  and 
direction  of  fissures. 

Contusions,  cracks,  and  fissures,  with  or  without  depres-. 
sion  of  the  inner  table,  are  of  delicate,  uncertain  diagnosis. 
The  last  will  be  suspected  when  the  finger  causes  pain  at 
a  distance  from  the  wound,  and  meningeal  irritation  points 
to  a  depression  of  the  inner  table  {pains  and  contraction  on  the 
side  corresponding  to  the  lesion).  As  a  rule,  in  these  injuries 
direct  exploration  must  he  avoided.     In  case  of  doubt  one  is 


WOUNDS  OF  THE  SKULL  AND  BRAIN      133 

to  act  as  if  the  suspected  lesion  existed.  Under  conditions 
of  absolute  asepsis  exploration  of  the  wound,  with  the  help 
of  an  incision  or  a  freeing  of  the  integuments  from  all  con- 
striction, may  be  warranted. 

On  the  other  hand,  in  the  other  varieties  of  injuries, 
particularly  in  furrows,  grooves,  perforation  of  a  single  wall^ 
tangential  perforations,  double  perforations,  in  which 
exploration  helps  to  confirm  a  diagnosis  which  may  require 
operative  interference,  aseptic  exploration  is  allowable  and  often 
necessary. 

Many  of  the  wounded  with  cranio-cerebral  traumatisms, 
who  get  beyond  the  first-aid  lines,  surprise  the  surgeon  by 
the  absence  or  the  attenuation  of  the  symptoms  they  pre- 
sent. Under  a  small  wound,  whose  edges  are  already 
adherent,  that  presents  but  slight  suppuration,  and  that 
might  be  taken  for  a  simple  wound  of  the  soft  parts,  the 
skull  is  found  to  be  gouged  out  or  perforated,  and  broken- 
down  cerebral  substance  is  seen.  If  the  wound  is  slightly 
raised,  it  is  due  to  a  small  cerebral  hernia.  These  soldiers 
have  often  walked  for  a  long  distance.  Nothing  in  their 
general  appearance  would  lead  one  to  believe  they  were 
suffering  from  a  serious  lesion  ;  they  talk,  eat,  they  take 
their  place  by  themselves,  and  cheerfully  too,  on  the  table 
for  surgical  dressing.  However,  if  one  is  warned,  in  some 
we  discover  a  certain  amount  of  indifference,  in  others 
some  want  of  intelligence.  The  absence  of  symptorns,  the 
readiness  with  which  their  cranio-cerebral  traumatisms 
are  mistaken  for  simple  wounds,  account  in  a  great 
measure  for  their  having  been  transported  over  long  dis- 
tances. We  have  already  seen  many  of  such  unfortunate 
patients.  The  prognosis,  so  favourable  at  the  beginnings 
deceived  us  in  the  same  way  that  their  diagnosis  had  already 
done. 

The  injuries  of  neutral  cerebral  zones  (frontal  region) 
may  not  be  revealed  by  any  symptoms.     In  general,  how- 


134     WOUNDS  OF  THE  SKULL  AND  BRAIN 

ever,  in  transverse  frontal  perforations  we  observe  blindness, 
anosmia,  strabismus. 

In  parietal  and  temporal  perforations,  disturbance  in  the 
mobility  of  the  limbs  and  face,  aphasia,  cecity,  visual 
disorder,  are  seen.  But  these  symptoms  may  be  absent 
or  but  little  marked. 

Occipital  perforations  may  give  rise  to  disturbance  of  sight 
and  of  equilibrium,  to  vertigo,  to  priapism. 

Antero-posterior  perforations  often  have  very  indistinct  symp- 
toms.    Vertical  perforations  are  nearly  always  rapidly  fatal. 

If  in  a  patient  with  a  great  number  of  wounds  we  notice 
signs  of  cerebral  shock,  the  disturbances  in  hearing,  sight, 
sensation  and  motion,  which  may  be  also  observed,  are  but 
transitory.  Moderate  or  severe  cerebral  shock  is  mainly 
connected  with  the  concussion  between  the  skull  and  shell 
fragments. 

Symptoms  of  compression  :  Disturbance  in  feeling,  in 
motion,  in  the  organs  of  sense,  loss  of  corneal  sensibility, 
mydriasis,  stertorous  respiration,  coma,  are  only  seen  in 
depressed  fractures  due  to  large  fragments  of  projectiles. 
In  military  cranial  lesions,  most  of  which  are  open,  these 
symptoms  are  hardly  ev^er  connected  with  haemorrhage; 
this  is  contrary  to  what  occurs  in  ordinary  practice. 

The  signs  of  contusion  are  deficit  signs.  They  may  be 
very  obvious  or  almost  absent. 

The  present  campaign  opens  up  to  neurologists,  as  well 
as  to  physiologists  and  to  French  surgeons,  a  wide  field  of 
study  which  should  not  be  lost,  and  to  which,  in  the 
author's  opinion,  sufficient  attention  is  not  paid.  Certain 
bullets  make  in  the  brain  paths  as  clean  and  as  simple  as 
those  produced  in  experiments  on  animals.  We  are  too  apt 
to  forget  that  when  these  last  were  undertaken  the  object 
was  to  study  a  symptomatology  and  certain  disturbances 
that  are  interpreted  and  sometimes  shown  by  our  wounded 
in  quite  a  different  manner. 


WOUNDS  OF  THE  SKULL   AND  BRAIN     135 

Evolution. — With  the  present  small  perforations  pro- 
duced by  rifle-bullets,  aseptic  evolution  is  far  less  rarely 
seen  than  in  former  times. 

Professor  Ferraton  regards  as  closely  connected  with  an 
attenuated  infection,  the  early  psychic  accidents  (maniacal 
excitement,  which  can  be  mistaken  for  alcoholic  delirium) 
and  other  cerebral  disturbances,  which  will  be  considered  in 
another  chapter  (epilepsy,  dementia,  etc.). 

It  is  infection  (through  hair,  shreds  of  headgear,  soiled 
bullets,  irregular  dressings,  etc.)  extending  from  light  sup- 
puration and  circumscribed  meningo-encephalitis  to  gene- 
ralized meningo-encephalitis,  that  makes  these  lesions  so 
dangerous,  and  causes  a  mortality  oscillating  between 
15  and  57  per  cent. 

Prognosis. — As  a  rule  the  prognosis  of  encephalic  lesions 
is  of  the  gravest.  Most  of  the  wounded  die  on  the  battle- 
field (from  40  to  55  per  cent.),  26  to  28  per  cent,  succumb 
in  the  ambulances  or  in  the  hospitals. 

The  prognosis  of  thvough-and-thwitgh  cranio-cerebral  per- 
forations is  the  most  severe  of  all.  Only  those  made  by 
bullets  of  low  velocity  (small  apertures)  can  be  studied. 
The  wounded  who  offer  resistance  to  the  first  symptoms 
surprise  the  surgeon  by  the  length  of  the  track  and  the 
benignity  of  the  sequelae,  but  this  cannot  make  us  forget  the 
large  number  of  soldiers  who  perished  shortly  after  their 
traumatism. 

Recoveries  from  single  perforations  by  bullets  are  less 
exceptional. 

Of  all  the  open  lesions,  grooves  are  the  less  serious  when 
they  are  properly  treated. 

Non-penetrating  wounds  heal  in  most  cases. 

In  lesions  produced  by  bullets  the  prognosis  is  in  general 
in  close  relationship  to  the  velocity  of  the  projectile  and  to 
the  importance  of  the  parts  involved.  Frontal  wounds  are 
the  less  severe.     Extensive  injuries  from  shell  fragments 


136     WOUNDS  OF  THE  SKULL  AND  BRAIN 

lead  as  a  rule  to  immediate  death.  Penetrations  from 
shrapnel  are  very  grave  (through  the  larger  diameter  of  the 
projectile  and  foreign  bodies). 

The  mortality  would  seem  to  be  1*7  per  cent,  for  the 
non-infected  (! !),  and  41*8  per  cent,  for  the  infected  wounds. 

Among  those  that  recover,  one-fourth  succumb  to  sequelae, 
and  at  least  one-half  of  the  remainder  are  left  permanently 
infirm. 

Treatment. — Lesions  of  the  skull  and  brain  are,  of  all 
those  involving  the  parenchymatous  organs,  the  ones  which 
are  in  the  greatest  need,  according  to  some  authorities,  of 
surgical  interference. 

.  In  their  treatment  it  would  be  wise  to  keep  within  a 
margin  of  systematic  abstention  and  systematic  interven- 
tion. 

Indications  relating  thereto  may  be  summed  up  as 
follows : 

1.  Contusions,  cracks,  a.nd  fissures  require  no  primary  interven- 
tion. It  is  only  in  fissures  complicated  by  depression  of  the 
inner  table  with  meningeal  or  cerebral  irritation  {pains  and 
contractions  on  the  same  side  as  the  lesion  in  cases  of  meningeal 
irritation  ;  pains  and  contractions  on  the  opposite  side  in  cases  of 
cerebral  irritation)  that  trephining  of  the  skitll  over  the  point  of 
impact  would  be  warranted. 

2.  Depressed  fractures  produced  by  large  shell  fragments, 
and  giving  rise  to  symptoms  of  compression,  necessitate 
raising  of  the  splinters,  and  not  their  removal.  Trephining 
is  here  only  a  procedure  to  facilitate  the  task  of  the  surgeon. 
The  trephine  must  not  be  employed  if  the  surgeon,  without 
its  use,  can  seize  the  splinter  where  it  has  passed  between 
the  fracture  and  the  dura  mater, 

3.  Single  perforations  must  be  treated  primarily  by  conservatism. 
If  by  enlarging  the  cranial  loss  of  substance  with  the  gouge 
or  the  trephine  free  access  is  obtained  to  the  loose  splinters 
of  the  jnner  table,  it  must  bg  rgrraembeped  that  these  splin? 


WOUNDS  OF  THE  SKULL  AND  BRAIN     137 

ters,  not  having  been  driven  forward,  are  seldom  irritating  ; 
that',  on  the  other  hand,  the  surgeon  who  wishes  to  operate 
can  do  nothing  to  rid  the  brain  of  spHnters  lodged  in  the 
track,  and  that,  moreover,  his  intervention  would  be  blam- 
able  if  he  wished  primarily  and  as  a  general  rule  to  search 
for  the  bullet  and  to  remove  it.  To  open  widely  these 
wounds,  which  are  generally  not  infected,  is  to  open  a  door 
for  infection  and  to  risk  cerebral  hernia. 

4.  Through-and-throitgh  perforation  must  be  treated  without 
operation.  In  these  grave  lesions,  to  increase  the  cranial 
opening  at  the  level  of  the  bony  aperture  of  entry  would 
only  facilitate  the  removal  of  the  sedentary  splinters  of  the. 
first  inner  table,  and  could  not  insure  either  the  removal  of 
organic  foreign  bodies  formed  of  shreds  of  clothing  or  of 
splinters  thrown  forward  into  the  track  or  into  its  extremi- 
ties. For  the  removal  of  the  superficial  splinters  located! 
near  the  orifice  of  exit  of  the  second  table  the  trephine; 
would  be  useless,  these  splinters  being  either  adherent,, 
when  they  should  be  kept  in  place,  or  free — that  is  to  say„ 
easily  extracted  without  trephining. 

5.  Grooves,  cranial  furrows,  remain  to  be  considered.. 
Their  treatment  forms  the  triumph  of  operative  surgery. 
Intervention  here  becomes  a  necessity  ;  it  gives  beneficial 
results  when  the  irreparable  loss  of  substance  to  which  the 
skull  is  subjected  is  not  excessive,  and  when  it  is  limited  to 
what  is  strictly  necessary. 

Here,  as  we  have  already  seen,  more  or  less  numerous 
splinters  derived  from  the  inner  table  have  been  liberated  ; 
often  they  have  been  depressed,  driven  into  the  cerebral 
substance.  The  encephalic  focus  is  superficial,  and  is  easy 
to  clean.  Therefore  there  is  good  reason  for  intervention  ; 
but  it  must  be  remembered  that  the  breach  is  long,  and  that 
one  is  liable  to  bring  about  very  extensive  and  regrettable 
loss  of  cerebral  substance  if  the  opening  be  too  freely  enlarged. 
It  is  not  the  procedure  of  a  true  surgeon  to  willingly  and 


138     WOUNDS  OF  THE  SKULL  AND  BRAIN 

uselessly  increase  disturbances  which  in  themselves  are 
already  severe. 

These  precepts  differ  from  those  of  daily  surgical  practice 
as  understood  by  many  surgeons,  who  advise  operation  not 
only  in  cases  of  well-atithenticated  bony  lesions,  but  also  when 
these  bony  lesions  are  only  suspected,  they  would  trephine 
even  in  cases  of  cracks  without  depression. 

Whatever  the  procedure  followed  in  rather  important 
cranio-encephalic  traumatisms,  the  wounded  men  suffering 
from  them  must  not  he  transported  to  a  great  distance.  Trans- 
port is  dangerous,  nearly  always  fatal.  Out  of  seventeen 
patients  who  had  been  trephined,  observed  by  Deljalitzky 
during  the  Manchurian  War,  thirteen  died  during  their 
transfer ;  the  four  others  arrived  at  Karbine  comatose. 

Complications. — The  principal  primary  complications  of 
cranio-encephalic  wounds  produced  by  projectiles  are — 
Meningo -encephalitis,  hernia  of  the  brain,  foreign  bodies. 

MeNINGO  -  ENCEPHALITIS,     AbSCESS     OF      THE     BrAIN. — 

Meningo-encephalitis,  the  most  formidable  complication  of 
traumatisms  of  the  brain,  is  less  frequent  nowadays  than 
formerly.  It  appears  from  the  third  to  the  sixth  day,  nearly 
always  in  the  generalized  or  circumscribed  form. 

Rise  of  temperature,  violent  headache,  phenomena  of  cerebral 
excitement,  are  the  first  symptoms.  The  wounded  man 
is  irritable,  cries  out,  grinds  his  teeth,  struggles,  tears 
away  the  dressings ;  slight  twitching  of  the  face  muscles, 
general  contractions,  unequal  pupils,  nausea,  vomiting,  are 
noticed ;  secretion  from  the  wound  dries  up,  and,  when  the 
wound  is  rather  large,  cerebral  hernia  appears. 

At  the  period  of  crisis  there  is  delirium,  also  clonic  spasms, 
localized  or  generalized  convulsions  ;  the  twitchings  become 
more  or  less  generalized ;  the  patient  makes  grimaces ;  the 
pulse  is  hard  and  slow. 

Twenty-four  hours  to  a  few  days  after  this  period  of  excite- 
ment we  arrive  at  the  period  of  paralysis,  characterized  by 


WOUNDS  OF  THE  SKULL  AND  BRAIN     139 

somnolence,  coma,  paralysis  of  the  senses,  cessation  of 
muscular  contraction.  The  wounded  man  passes  away  in 
a  condition  of  collapse  usually  between  the  fourth  to  the 
eighth  day  after  the  outbreak. 

Irritative  and  depressive  symptoms  may  appear  in  turn  ; 
at  other  times  either  irritative  or  depressive  phenomena  are 
predominant. 

Localized  cerebral  infection,  superficial  or  deep,  like 
intracerebral  abscess,  is  either  of  rapid  or  of  slow  appari- 
tion. They  may  appear  several  months  after  the  traumatism. 
Violent  pains,  irritability  of  the  wounded  man,  twitchings, 
disturbances  of  the  depressive  class,  indications  of  cerebral 
compression,  are  the  general  signs  to  which  sometimes  are 
superadded  symptoms  of  localization.  If  the  dura-mater  is 
exposed,  it  is  deprived  of  its  undulatory  motion. 

Cerebral  abscesses  are  frequent  after  bullet  wounds. 
They  are  early  (two  to  fifteen  days)  or  tardy  (a  few  weeks 
to  some  months)  (H.  Billet). 

From  a  curative  point  of  view,  we  are  still  almost  dis- 
armed when  dealing  with  generalized  meningo-encephalitis 
(Billet).  Largely  opening  the  skull  with  the  toilet  of  the  cerebral 
coverings  (Hoisley),  trephining,  with  meningeal  drainage  (Mignon, 
Poirier),  are  uncertain  in  their  results. 

Lnmhar  puncture  (Chasteney  de  Giry,  Meslier,  Auvray), 
more  simple  in  technique,  is  perhaps  more  worthy  of  re- 
commendation, and  should  be  systematically  employed 
(Billet).  It  should  be  repeated  every  day,  and  even  if 
necessary  twice  a  day  (Billet) ;  at  the  same  time  free 
incisions  should  clear  the  wound,  or  wounds,  of  all  con- 
striction, with  careful  disinfection,  and  puncture  of  the 
cerebral  substance  should  be  resorted  to  in  search  of  the 
abscess  (tardy  symptoms). 

The  treatment  should,  above  all,  be  preventive.  Cerebro- 
spinal meningitis  is  especially  observed  in  men  with  tan- 
gential wounds  or  lesions  due  to  shrapnel  bullets,  and  these 


HO     WOUNDS  OF  THE  SKULL  AND  BRAIN 

cases  are  precisely  those  in  which  primary  intervention  is 
justifiable  (Billet).  Puncture  should  be  carried  out  from 
the  appearance  of  the  first  symptoms.  Symptoms  which 
impel  us  to  employ  surgical  intervention  are  fever,  fre- 
quency of  pulse,  presence  of  microbes  in  the  fluid  obtained 
by  lumbar  puncture  (meningitis).  In  abscess  this  fluid  is 
not  turbid,  but  clear  (Auvray). 

In  cerebral  abscess  we  must  intervene  when  we  see  some 
signs  of  the  necessity  of  doing  so  (hernia). 

Hernia  of  the  Brain. — This  is  a  very  frequent  complica- 
tion, which  occurs  in  two  forms  :  primarily^  from  twenty-four 
to  thirty-six  hours  after  traumatism,  as  a  diflluent  prolapse 
of  the  brain,  with  either  an  almost  normal  aspect,  in  which 
splinters  of  bone  are  found,  or,  consecutively,  as  a  mass,  the 
size  of  a  nut,  a  hen's  egg,  an  orange,  dark  reddish  in  colour, 
turgid,  fleshy,  partly  reducible,  but  whose  reduction  may 
bring  on  comatous  or  convulsive  symptoms. 

Hernia  is  generally  the  sign  of  the  evolution  of  meningo- 
encephalitis or  of  a  cerebral  abscess. 

It  is  very  frequently  the  regrettable  consequence  of  the  extensive 
cranial  dilapidations  caused  by  the  surgeon.  Therefore  it  is 
a  good  reason  to  raise  against  systematic  trephining  (H. 
Billet). 

Hernia  of  the  brain  is  a  very  serious  complication.  Dur- 
ing the  recent  wars  the  mortality  fluctuated  between  54  and 
58  per  cent.  (Billet). 

To  hinder  infection,  to  avoid  large  surgical  losses  of  sub- 
stance, constitute  in  these  cases  the  basis  of  preventive 
therapeutics. 

Ligature,  excision,  strong  compression,  are  condemned.  We 
must  content  ourselves  with  exercising  slight  compression, 
dressing  at  rare  intervals,  and  carrying  out  a  puncture,  if 
we  suspect  an  abscess  ;  finally,  we  must  treat  the  meningitis. 
Subsequently  the  surface  of  a  granulating  and  irreducible 
hernia  should  be  covered  with  skin. 


WOUMDS  of  the  skull  and  brain      i4i 

Foreign  Bodies. — The  foreign  bodies  implicated  in  intra^ 
cerebral  tracks  are  projectiles  (rifle  bullets,  entire  or  in 
fragments,  changed  in  shape  or  deflected,  shrapnel  bullets, 
and  especially  shell  fragments)  ;  in  half  of  the  cases  they 
are  shreds  of  headgear,  pieces  of  hair,  and  projected  splinters. 

The  presence  of  one  single  penetration  is  almost  pathog- 
nomonic of  the  presence  of  a  projectile,  but  radiography 
alone  can  establish  both  the  general  diagnosis  and  the 
localization. 

Primarily,  systematic  abstention  from  searching  for 

THE  PROJECTILE  IN    INJURIES    FROM    RIFLE    BULLETS    SHOULD 
BE  THE  RULE. 

Abstention  from  systematic  search  for  intracerebral  splinters 
should  also  be  the  general  rule.  It  is  impossible  to  discover 
their  location  ;  their  removal  would  expose  the  patient  to 
excessive  damage,  and  might  not  be  complete.  Impossible 
also  is  the  removal  of  shreds  of  headgear,  the  presence  of 
which  has  been  revealed  by  a  loss  of  substance  in  the  head- 
dress. 

The  present  bullets  are  often  tolerated.  They  may  be  extracted 
SUBSEQUENTLY,  but  ojtly  whcn  their  presence  is  unbearable. 
We  are  inclined  to  advise  an  early  removal  of  shrapnel 
bullets  and  of  shell  fragments  that  carry  with  them  and  so 
often  hold  infecting  foreign  bodies,  provided,  however, 
these  bullets  and  shell  fragments  have  previously  been 
carefully  located  by  radiography. 

Removal  by  forceps  may  give  rise  to  further  damage. 
For  removing  metallic  foreign  bodies  we  would  advise  the 
use  of  a  curette  mounted  on  a  handle.  This  curette  is 
similar  to  a  urethral  extractor  scoop,  and  can  be  bent. 

Symptoms  Consecutive  to  Traumatisms  of  the  Skull 
AND  Brain. — Let  us  pass  by  adherent  cicatrices,  cranial 
losses  of  substance  that  are  somewhat  extensive  and  so 
difEcult  to  repair  with  raised  cicatrices,  badly  protecting  the 
brain  from  noises  that  cause  pain  when  they  strike  on  it. 


142     WOUNDS  OF  THE  SKULL  AND  BRAIN 

Solutions  of  continuity  one  is  obliged  to  cover  with  india- 
rubber  plates. 

Cerebral  disturbance  consecutive  to  injuries  of  the  skull 
and  brain  constitutes  one  of  the  most  mournful  pages  in  the 
history  of  these  wounds.  This  disturbance  is  extremely 
frequent.  Thus,  among  the  considerable  number  of 
wounded  in  the  Secession  War,  only  two  presented  no  cerebral 
distnrhance.  A  very  large  majority  of  the  men  violently  struck 
on  the  head  in  warfare  are  brain  patients  constantly  tinder  the 
influence  of  extremely  grave  cerebral  disease  (Lasegue),  and  who 
for  this  very  reason  have  claims  to  the  good-will  and  charity 
of  the  War  Office  authorities. 

Another  peculiarity  in  the  history  of  these  cases  is  that 
these  troubles  very  often  appear  at  a  remote  date  from  the  trau- 
matism. 

The  military  surgeon  should  constantly  bear  in  mind 
these  data. 

These  troubles  are  of  various  kinds  :  {a)  Psychic,  (b)  sensi- 
tive or  (c)  sensorial,  (d)  motor. 

Billet,  according  to  Holbeck,  has  established  their  pro- 
portion. It  would  be  necessary,  however,  to  complete 
on  a  larger  basis  the  ratios  observed  up  to  the  present 
time. 

The  most  usual  psychic  disorders  have  to  do  with  modifi- 
cations of  character  :  the  various  kinds  of  memory  are 
diminished  or  abolished  {simple  amnesia^  retrograde  amnesia — 
that  is  to  say,  loss  of  remembrance  of  events  that  happened 
prior  to  the  wound) ;  they  manifest  themselves  by  all  the 
varieties  of  insanity,  mainly  melancholia  and  dipsomania,  acute 
mania,  general  paralysis.  Medical  men  have  wished  to  make 
predisposition  play  an  important  part  in  these  manifestations. 
It  would  be  more  just  and  true  to  reduce  this  importance 
(Delorme).  Besides,  even  if,  with  certain  wounded,  pre- 
disposition did  exist,  it  should  in  no  wise  lessen  their  claims 
to  a  pension. 


WOUNDS  OF  THE  SKULL  AND  BRAIN     143 

Violent  and  persistent  pains,  vertigo,  either  spontaneous  or 
on  th'e  slightest  inclination  of  the  head,  are  usual. 

Impairment  of  hearing,  of  sight,  of  taste,  are  very  frequent. 

Contractions,  especially  epilepsy,  are  very  frequently 
observed. 

Traumatic  epilepsy  seems  specially  to  depend  on  two  causes : 
inclusion  of  a  projectile  or  of  bony  spiculse  in  the  brain, 
cerebral  irritation  caused  by  a  cicatrix  which  creates  an 
epileptogenic  zone  (Billet).  It  therefore  seems  that  in  these 
two  categories  of  facts  operative  cure  ought  to  be  attempted 
in  spite  of  reservations  that  might  be  made  as  to  the  thera- 
peutic value  of  these  interventions  (excision  of  the  cicatrix, 
removal  of  the  foreign  bodies). 

In  cases  of  Jacksonian  epilepsy,  operation  seems  more 
prejudicial  than  serviceable. 

The  failure  of  surgical  intervention  seems  to  be  due  to  the 
fact  that  it  is  impossible  to  remove  all  cerebral  cicatricial 
lesions  and  to  prevent  their  return. 

Deficit,  consecutive,  and  motor  troubles  manifest  them- 
selves by  more  or  less  persistent  paralysis. 

Legal  Position  of  Soldiers  wounded  in  the  Skull 
AND  Brain. — To  the  fourth  class  of  infirmities  that  give 
a  right  to  a  pension,  belong  the  wounded  who  present : 

1.  Complete  hemiplegia  or  complete  paraplegia  of  trau- 
matic origin. 

2.  Grave  deterioration  of  cerebral  functions — loss  of 
memory,  of  speech,  imbecility,  dementia,  insanity,  etc. — 
resulting  from  a  wound  of  the  head. 

3.  General  paralysis,  with  incontinence. 

The  following  wounded  necessarily  figure  in  the  fifth 
class.     Those  presenting — 

1.  Incomplete  hemiplegia  or  incomplete  paraplegia. 

2.  General  progressive  paralysis  at  the  critical  stage. 

3.  Epilepsy,  epileptiform  fits,  functional  spasms  resulting 
from  a  traumatism. 


144     WOUNDS  OF  THE  SKULL  AND  BRAIN 

4.  Paralysis  of  an  important  organ  (muscles  of  the 
'eye,  etc.). 

5.  Extensive  and  deep  cicatrix  of  the  skull,  with  loss  of 
: substance  of  the  pericranium  and  of  the  bones  in  their 
^entire  thickness. 

In  the  sixth  class  we  have  the  wounded  who  present : 
A  persistent  fistula,   the   result   of  necrotic   or   carious 
periostitis. 


CHAPTER  XIII 
WOUNDS  OF  THE  FACE 

They  are  as  frequent  as  the  wounds  of  the  skull. 
Although  several  of  the  regions  of  the  face  may  be  injured 
simultaneously,  distinction  should  be  made  between  the 
wounds  of  the  nose,  of  the  orbit  and  eye,  of  the  ear,  of  the 
superior  maxillary,  of  the  mouth,  of  the  inferior  maxillary,  each 
of  which  should  be  studied  separately.  Rifle  fire  that  hits 
this  region  is  antero-posterior,  transverse,  vertical,  sometimes 
direct,  sometimes  oblique. 

Wounds  of  the  Nose. — The  nose  when  struck  by  a 
sword  or  a  large  shell  fragment  may  be  partially  or  entirely 
severed  from  the  face,  together  with  a  part  of  the  superior 
maxilla.  Bullets  indent  it,  or  more  commonly  perforate  it. 
The  damage  is  generally  limited.  Struck  by  antero- 
posterior or  lateral  firing  at  a  short  distance,  the  nose  may 
be  divided  into  several  parts  or  split  up. 

The  wounds  heal  without  complications.  Hydrogen 
peroxide  (diluted  by  half)  is  one  of  the  best  antiseptics  for 
these  lesions,  which  usually  suppurate.  Even  when  they 
are  very  bruised,  all  osseoiis  or  cutaneous  fragments  must  he 
carefully  preserved  ;  they  will  be  held  in  place  by  nasal 
tamponade. 

In  large  traumatisms,  autoplasty  and  prosthesis  provide 
the  surgeon  with  admirable  expedients. 

Wounds  of  the  Orbit  and  of  the  Eye.— Direct  lesions 
of  the  bones  of  the  orbit  are  notches,  indentations,  perfora- 

145  ^° 


146  WOUNDS  OF  THE  FACE 

tions,  with  sJiort,  thin,  and  dry  splinters.  Indirect  or 
extended  lesions  are  fissures  radiating  from  the  base  of  the 
skull. 

Bullets  often  pass  through  the  orbit  without  touching  the 
eye  or  the  optic  nerve.  On  other  occasions  this  nerve,  as 
well  as  the  other  nerves  in  its  neighbourhood,  is  contused, 
indented,  divided. 

Rapid  ecchymosis,  palpebral  swelling,  occasionally  ex- 
ophthalmiaj  are  the  immediate  signs  of  wounds  of  the 
orbit. 

The  evolution  of  these  lesions  is  nearly  always  simple, 
and  their  dressing  presents  nothing  particular.  When  in- 
fected, they  may  give  rise  to  abscess  of  the  orbit,  and 
threaten  the  meninges. 

An  external  incision  gives  issue  to  pus. 
Of  frequent  occurrence,  the  injuries  of  the  eye  consist  of 
contusions,  with  or  without  hernia  of  the  iris,  dislocation  of 
the  lens,  detachment  of  the  retina,  tearing  of  the  choroid, 
of  slight  or  large  wounds ^  of  perforations,  abrasions,  rupture. 

At  first  the  diagnosis  is  either  obvious  or  very  obscure. 
In  trying  to  localize  it,  one  finds  that  functional  troubles, 
diminution  or  loss  of  sight,  can  arise  from  very  diverse 
causes. 

Radiography  will  determine  the  presence  and  seat  of 
metallic  foreign  bodies.  ^ 

In  some  cases  these  wounds  heal  without  complications  ; 
in  others  the  cornea,  the  iris,  the  choroid,  become  inflamed. 
The  vitreous  becomes,  easily  infected.  Panophthalmia 
is  common. 

Sympathetic  ophthalmia  is  frequent.  It  is  one  of  the 
most  serious  complications  of  lesions  of  the  eye.  It  appears 
sometimes  very  quickly,  sometimes  in  the  course  of  the 
year  following  the  wound — a  fact  which  must  not  be  lost 
sight  of  by  the  skilful  medical  man. 

Antiseptic  dressings  of  iodoform  ointment  are  used  at 


WOUNDS  OF  THE  EAR  147 

first ;  certain  lesions  of  the  cornea,  the  iris,  the  sclerotic, 
may  need  suturing.  Immediate  enucleation  is  the  treat- 
ment of  extreme  irremediable  wounds,  or  of  those  that  are 
complicated  by  the  presence  of  foreign  bodies.  It  must 
not  be  forgotten  that  this  is  preferable  to  conservation  by 
reason  of  its  being  less  often  followed  by  sympathetic 
troubles. 

Wounds  of  the  Ear. — They  rarely  are  seen  alone ;  in 
most  cases  they  are  accompanied  by  concomitant  lesions 
of  the  skull  and  of  the  face ;  they  result  from  antero- 
posterior and  transverse  firing. 

In  artillery  fire  and  explosions,  ruptures  of  the  tym- 
panum (oozing  of  blood  from  the  ear),  concussion  of  and 
haemorrhage  from  the  labyrinth,  are  by  no  means  rare. 

^Bullets  and  shell  fragments  notch,  perforate,  partially 
destroy,  the  pinna  ;  gouge  out  and  penetrate  into  the  bony 
auditory  canal  or  the  mastoid  process ;  invade  the  petrous 
bone  as  far  as  the  interior  of  the  cranium,  and  gouge  or 
perforate  the  petrous  bone  itself. 

Wounds  of  the  large  vessels  closely  connected  with  the 
ear  give  rise  to  dangerous  haemorrhage  (internal  carotid, 
branches  of  the  external  carotid,  internal  jugular,  trans- 
verse sinus) ;  but  even  independently  of  any  injury  to  these 
large  vessels,  external  and  buccal  haemorrhage  is  frequent. 
The  loss  of  cerebro-spinal  fluid,  of  broken-down  cerebral 
pulp,  implies  some  cerebral  complication  ;  lesions  of  the 
facial  nerve,  of  the  trigeminus,  are  revealed  by  their  ordinary 
signs.     Those  of  the  facial  are  not  rare. 

Diminution  or  loss  of  hearing  is  nearly  certain  in  deep 
wounds  of  the  ear,  and  secondary  psychic  troubles  occur 
pretty  frequently.  These  wounds  rarely  remain  aseptic  ; 
they  nearly  always  suppurate,  and  the  pus  may  burrow  even 
into  the  neck. 

Treatment  at  first  comprises  instillations  of  carbolized 
glycerine   and   iodoform   or   iodine,    the   introduction  of  a 


148  WOUNDS  OF  THE  FACE 

drain  of  aseptic  or  iodoform  gauze,  and  bucco-pharyngeal 
disinfection.  No  splinters  should  be  extracted,  excepting 
those  that  are  free;  removal  of  adherent  splinters  would 
render  the  patient  liable  to  dangerous  haemorrhage. 

Foreign  bodies  are  subsequently  taken  away  by  the 
retro-auricular  route  after  petro-mastoid  clearing  out. 

Wounds  of  the  Upper  Maxillae.— On  their  edges  the 
upper  maxillae  are  notched  ;  in  their  body  they  are  perforated 
(bullets)  or  abraded  with  comminution  (shell  fragments), 
occasionally  separated  as  a  whole,  and  dislocated  from  the 
rest  of  the  bones  of  the  face,  or  separated  one  from  the 
other  in  the  middle  line  at  the  time  they  are  perforated  by 
bullets  travelling  with  great  velocity. 

Injury  of  the  alveolar  border  is  complicated  with  dental 
traumatisms,  fractures,  tearing  out,  with  propulsions  of  the 
teeth. 

The  splinters  are  generally  short. 

Notwithstanding  the  communication  of  the  osseous  focus 
with  the  nasal  fossae  and  the  mouth,  the  evolution  of  these 
wounds  is  usually  benign,  even  when  there  is  extensive  loss 
of  substance  with  large  external  lesions. 

The  prognosis  of  these  injuries  is  in  the  main  not  serious, 
provided  the  surgeon  secure  buccal  antisepsis,  the  danger 
lying  in  the  continual  dropping  into  the  buccal  cavity  of 
septic  products  arising  from  the  seat  of  the  fracture. 

Gargling  or,  better  still,  very  frequent  irrigations  by  large 
glassfuls  during  the  first  days,  besides  those  taken  imme- 
diately before  any  food  or  drink,  are  to  be  preferred  to  a 
drain  of  antiseptic  gauze. 

Hydrogen  peroxide  is  excellent  in  these  cases.  In  its 
absence  we  can  employ  potassium  permanganate  solution 
(i  in  4,000),  boric  or  iodized  solutions,  even  simple  boiled 
water.  Some  wounded  men  are  quite  capable  of  doing  their 
irrigation  themselves  both  by  day  and  by  night. 

The  diet  should  be  liquid,  at  least  for  the  first  days.     The 


WOUNDS  OF  THE  INFERIOR  MAXILLA     149 

liquid,  food  should  be  introduced  behind  the  dental  arches 
through  an  india-rubber  tube  supplied  with  a  small  funnel. 

A  bandage  to  support  the  chin,  ligation  of  the  teeth, 
suturing,  will  all  help  to  keep  the  loose  fragments  in 
place.  Not  one  of  these  last  should  be  sacrificed  even  if 
they  are  very  loose.  At  the  rear,  in  severe  cases,  these 
first  means  will  be  replaced  by  provisional  intrabuccal 
prosthetic  apparatus. 

The  slightest  portion  of  the  soft  parts  covering  the 
superior  maxillae  that  have  been  lacerated  by  bullets  or 
shell  fragments  should  be  preserved.  Median  or  lateral 
losses  of  substance  on  the  roof  of  the  hard  palate  are 
generally  repaired  by  prosthetic  apparatus. 

Wounds  of  the  Inferior  Maxilla.  —  The  inferior 
maxilla,  a  compact  bone,  presents  lesions  comparable  to 
those  of  the  diaphysis.  The  borders  are  gouged,  furrowed  by 
oblique  fissures,  with  cuneiform  direction  of  the  grooves. 
Perforations  are  complicated  by  radiated  X-shaped  fissures, 
like  perforations  of  the  diaphysis.  The  line  of  fracture  is 
rarely  simple,  and  represented  by  one  or  two  vertical  or 
oblique  lines.  The  teeth  are  fractured,  pushed  or  propelled 
out  of  their  alveolar  cavities.  Splinters  are  relatively  not 
very  extensive  ;  they  are  maintained  in  position  by  the  thick 
periosteum,  the  mucous  membrane,  and  the  attachments  of 
the  muscles,  they  may,  however,  be  displaced. 

Nearly  always  there  is  no  displacement  of  the  large 
fragments.  Sometimes  they  tilt  inwards,  exceptionally  out- 
wards ;  most  frequently  forwards  and  downwards  through 
the  action  of  the  genio-hyo-glossus  and  genio-hyoid  muscles. 
In  some  cases  there  is  overlapping. 

Fragments  of  large  projectiles  occasion  contusions,  simple 
fractures  after  tangential  contact,  or  else  partial  or  total 
abrasions  of  the  body  of  the  maxilla.  When  the  lesion 
involves  the  body  of  the  bone,  the  result  is  a  large  buccal 
hiatus,  open  in  front,  invaded  by  the  tongue,  which  hangs 


I50  WOUNDS  OF  THE  FACE 

out  in  front  of  the  neck.  With  less  severe  injuries  and 
separation  of  the  genio-hyo-glossi,  the  tongue  rather  tends 
to  drop  back  into  the  larynx. 

Very  different  from  the  injuries  of  the  superior  maxilla, 
which  in  the  majority  of  cases  are  benign,  those  of  the 
inferior  maxilla  must  always  be  looked  upon  as  grave. 
Local  infection  is  the  rule ;  pus  accumulates  and  remains 
in  the  buccal  floor,  and  is  continually  being  swallowed. 
Purulent  general  infection  is  very  frequent.  Osteitis  or 
necrosis  of  fragments,  both  long  and  difficult  to  repair,  at 
times  osteomyelitis — such  are  the  consequences  of  localized 
infection. 

Treatment  must  fulfil  three  conditions  :  (i)  It  must  secure 
incessant  disinfection  of  the  mouth;  (2)  facilitate  easy  draining 
for  septic  fltiids  to  the  outside  of  the  mouth  ;  {^)  obtain  immobiliza- 
tion of  the  fragments. 

1.  All  we  have  said  regarding  disinfection  of  the  mouth 
in  reference  to  the  superior  maxilla  is  applicable  to  the 
inferior. 

2.  Inclining  the  head  forward ;  in  case  of  need,  an 
incision  made  under  the  maxilla,  insuring  permanent  intra- 
and  extra-buccal  drainage,  realizes  the  second  condition. 

3.  As  for  immobilization,  it  is  attained  either  by  fastening 
the  teeth  together  by  ligatures,  or  by  maintaining  the  inferior 
maxilla  against  the  superior  by  means  of  a  chin  bandage. 
By  inserting  between  the  dental  arches  a  flat  but  thick 
piece  of  cork  hollowed  into  a  double  groove,  or  a  slab 
of  guttapercha,  thus  leaving  a  free  space  between  the 
maxillae,  we  facilitate  buccal  disinfection,  and  at  the  same 
time  maintain  coaptation  of  the  fragments.  Direct  suturing 
has  its  advocates,  but  it  should  mainly  be  used  in  simple 
fractures. 

We  must  respect  splinters  that  have  not  been  moved,  even  when 
they  are  only  very  slightly  adherent,  in  order  to  avoid  consecutive 
deviations  towards  the  buccal  axis.  Fragments  that  have 
b  een  pushed  forward,  like  a  free  tooth,  must  be  removed. 


WOUNDS  OF  TONGUE  AND  BUCCAL  FLOOR    151 

Haemorrhage,  a  quite  frequent  complication,  is  arrested 
at  first  by  compression,  then  by  ligation.  As  to  foreign 
bodies,  which  usually  cause  a  great  deal  of  irritation,  they 
must  be  removed  at  an  early  period. 

Subsequently  loss  of  substance  is  filled  up  by  prosthesis, 
and  deviations  are  corrected  by  apparatus,  which  make 
good  in  the  necessary  places  the  damage  that  the  maxilla 
has  suffered  (Preterre). 

Wounds  of  the  Tongue  and  the  Buccal  Floor.— 
Bullets  striking  the  tongue  produce  furrows,  setons,  cul-de- 
sac  wounds,  or  total  perforations.  They  generally  bring 
with  them  splinters  or  teeth  that  have  been  detached  from 
the  maxilla,  especially  from  the  inferior  maxilla. 

These  wounds  are  sometimes  complicated  by  abundant 
haemorrhage,  and,  if  they  frequently  end  without  septic 
accidents,  yet  on  other  occasions,  though  far  more  rarely 
nowadays  with  the  present  small  bullets,  they  give  rise  to 
abscesses  of  the  buccal  floor,  to  septicaemia  caused  by 
the  patient  swallowing  the  intrabuccal  fluids,  and  finally  to 
glossitis. 

The  most  common  treatment  required  by  wounds  of  the 
tongue  is,  in  case  of  severe  haemorrhage,  obturation  of  the 
buccal  wound  by  tamponade  or  suturing ;  uninterrupted 
detersion  of  the  mouth,  relief  by  incisions  of  all  constriction 
in  the  wound,  and  search  for  foreign  bodies  which  may  be 
lodged  in  the  tongue,  if  we  find  there  is  glossitis,  which 
causes  so  much  trouble  in  deglutition  and  respiration  ;  also 
median  or  lateral  incision  of  the  buccal  floor,  which  should 
include  the  whole  mylo-hyoid  band,  in  order  to  give  issue 
to  the  fluids  of  the  cellular  sublingual  tissue  ;  also  angular 
sterno-mastoid  incision  to  open  up  the  peripharyngeal 
collections. 

Wounds  of  the  lips  and  cheeks  present  no  special  par- 
ticularities. Strips  of  flesh  from  the  lips,  even  when  very 
much  contused,  must  be  carefully  preserved.  Lesions  of 
Stenon's  duct  are  exceptional. 


CHAPTER  XIV 

WOUNDS  OF  THE  NECK 

The  proportion  of  lesions  of  the  neck  is  i  to  3  per  cent,  of 
all  the  wounds  treated,  but  the  number  would  increase  by  3 
per  cent,  if  we  take  into  account  all  the  immediate  deaths 
that  occur. 

Two-thirds  of  these  wounds  are  simple  (Ferraton). 

Those  of  the  larynx  and  the  oesophagus  would  be  excep- 
tional. Wounds  of  the  neck  often  involve  the  cervical  part 
of  the  vertebral  column. 

The  track  may  be  antero -posterior ^  transverse  or  vertical, 
direct  or  oblique. 

The  antero-posterior  pretty  frequently  involves  isolated 
organs  ;  on  the  other  hand,  it  often  includes  injury  to  the 
vertebral  column  ;  deep  transverse  tracks  lead  to  more  com- 
plex lesions.  Wounds  of  the  supra-hyoid  and  of  the  upper 
supra-clavicular  regions  are  not  so  serious  as  those  of  the 
parotido-carotid  and  sub-hyoid  regions.  Wounds  of  the 
posterior  regions  of  the  neck  are  the  least  serious. 

Wounds  of  the  Nape  of  the  Neck. — Let  us  simply 
call  attention,  without  dwelling  upon  the  subject,  to  more 
or  less  deep  cuts  or  stabs  given  by  cold  steel  on  the  nape  of 
the  neck.  Bullets  hollow  out  in  this  region  either  short 
or  extensive  tracks,  with  or  without  haematomata;  shell 
fragments  leave  large,  deep  furrows,  extending  as  far  as  the 
vertebral  column. 

152 


WOUNDS  OF  ANTERO-LATERAL  REGIONS  153 

The^e  wounds  are  benign ;  there  is  nothing  particular  in 
their  treatment. 

Wounds  of  the  Antero  -  Lateral  Regions  —  Soft 
Parts. — They  comprise  the  supra-  and  sub-hyoid  regions, 
that  contain  the  laryngo-tracheal  and  pharyngo-oesophageal 
passages ;  they  also  comprise  the  carotido-parotid  regions 
abounding  in  large  vessels  and  nerves. 

The  lesions  of  the  sterno-mastoid,  and  of  the  other 
cervical  muscles,  consist  of  notches,  perforations,  and 
sections. 

Wounds  of  the  carotid  or  of  the  subclavian  arteries 
are  contusions,  lateral  wounds,  perforations ;  only  fragments 
from  large  projectiles  give  rise  to  sections. 

Haemorrhage  from  the  carotids  is  nearly  always  fatal. 
Nevertheless,  arterial  haematomata  are  sometimes  seen. 
These  haematomata,  which  take  on  a  very  rapid  develop- 
ment, cause  grave  compression  accidents,  implicating  the 
vessels,  the  nerves,  the  laryngo-tracheal  and  oesophageal 
passages,  denoted  by  circulatory  troubles  in  the  head  and 
brain,  and  nervous  and  respiratory  troubles,  dyspnoea, 
suffocation.  They  diffuse  as  far  as  the  axilla  and  the 
mediastinum.  The  blood  from  these  arteries  penetrates 
sometimes  into  the  larynx  or  the  trachea,  giving  rise  to 
bloody  expectoration,  causing  grave  or  fatal  haemoptysis, 
asphyxia ;  if  the  blood  flows  into  the  pharyngo-oesophageal 
canal,  it  is  either  swallowed  or  vomited. 

Open  lesions  of  big  veins  [lateral  wounds  and  perforations) 
give  rise,  according  to  the  diameter  of  the  external  wounds, 
to  very  abundant  haemorrhage  or  to  venous  haematomata. 

Wounds  of  very  big  veins,  such  as  the  internal  jugular, 
the  sub-clavian,  the  venous  brachio-cephalic  trunk,  are  as 
grave  as  those  of  the  accompanying  arteries.  Their  size, 
the  absence  of  valves,  and  the  resulting  emptiness  of  the 
cranial  sinuses,  render  haemorrhage  from  the  internal  jugular 
particularly  formidable. 


154  WOUNDS  OF  THE  NECK 

Lesions  of  the  nerves  of  the  neck  present  no  particular 
anatomo-pathological  characteristics. 

A  bullet  does  not  fracture  the  larynx  or  the  trachea  in  the 
ordinary  meaning  of  the  word ;  it  causes  contusmts,  indenta- 
tions, clean  perforations. 

These  indentations  and  perforations  bleed  moderately, 
but  they  remain  widely  open  ;  the  result  is  that  in  cases  of 
simultaneous  lesions  of  the  neighbouring  large  vessels  the 
blood  runs  freely  into  the  respiratory  passages. 

The  thyroid  is  indented  or  perforated.  A  bulky  fragment 
of  a  large  projectile  may  partially  abrade  it,  as  it  also  might 
abrade  the  larynx  or  the  trachea. 

The  pharynx  and  oesophagus  are  contused  or  perforated.  In 
the  case  of  the  oesophagus  it  is  rather  difficult  to  recognize 
the  lesion  at  first  sight  if  the  tube  has  not  been  artificially 
dilated. 

Diagnosis. — In  the  narrow  wounds  produced  by  bullets 
the  diagnosis  of  pharyngo-oesophageal  lesions  becomes 
very  difficult ;  it  remains  uncertain  in  the  large  majority 
of  cases.  The  escape  of  food  and  saliva,  a  pathognomonic 
sign,  is  wanting.  Dysphagia,  pain  or  difficulty  in  deglu- 
tition, will  be  about  the  only  signs,  sometimes  with  vomiting 
of  blood,  which  is  rare.  In  case  of  doubt,  one  should  act  as 
if  the  pharyngo-oesophageal  lesion  existed,  and  be  ready  to 
interfere  at  the  slightest  threatening  of  peri-oesophageal 
infection. 

Wounds  of  the  laryngo-tracheal  passage  by  projectiles 
hardly  ever  are  recognized  by  the  noisy  entrance  or  escape 
of  air  through  the  cervical  wound,  a  pathognomonic  sign. 
The  diagnosis  may,  perhaps,  be  rendered  less  difficult  by 
the  rapid  apparition  of  an  extensive  and  deep  emphysema. 
Cough  coming  on  in  fits,  asphyxiant  dyspnoea,  bloody 
expectoration,  aphonia,  which  occurs  in  subglottic  wounds, 
finally,  the  relations  of  the  track  with  the  respiratory  pas- 
sages   will   furnish  the    rudiments    of    the    diagnosis.     The 


WOUNDS  OF  ANTERO-LATERAL  REGIONS  155 

most  characteristic  symptom  of  penetrating  wounds  of  the 
laryngo-tracheal  passage  is  dyspnoea,  with  threatening 
asphyxia. 

In  cases  of  simultaneous  lesion  of  the  respiratory  and 
oesophageal  passages,  ingested  fluid  will  pass  into  the 
trachea,  and  may  be  expelled  by  cough  or  through  the 
cervical  wound;  but  we  must  not  rely  on  this  symptom, 
for  it  is  rather  by  the  whole  of  the  preceding  signs  that 
these  wounds  are  recognized. 

To  establish  the  origin  of  alarming  haemorrhage  is  usually 
very  difficult,  because  of  the  number  and  the  close  relation- 
ship of  the  large  jugulo-carotid  vessels. 

The  disappearance  of  temporal  or  radial  peripheral  pulse 
is  not  always  an  indication  of  a  carotid  or  subclavian 
section  (collateral  circulation,  compression  by  a  haematoma). 

Nearly  always  the  diagnosis  of  nervous  lesions  will  not 
be  made  until  at  a  period  more  or  less  remote  from  the 
date  of  the  traumatism  (Ferraton).  At  first  their  sympto- 
matology is  masked  by  that  of  the  neighbouring  lesions,  the 
extreme  gravity  of  which  occupies  all  our  whole  attention. 

Wounds  of  the  thyroid  body  are  diagnosed  by  the  rela- 
tions of  the  external  lesions,  by  haemorrhage  (which 
generally  is  moderately  abundant),  and  by  the  appearance 
of  a  haematoma. 

Prognosis. — The  evolution  of  the  injuries  of  the  neck  by 
projectiles  is  frequently  aseptic  when  the  soft  tissues  are 
the  only  ones  involved.  On  the  other  hand,  lesion  of  the 
laryngo-tracheal  and  pharyngo-oesophageal  passages,  the 
presence  of  foreign  bodies,  wide-spreading  haematomata, 
promote  or  favour  the  development  of  circumscribed  or 
diffuse  abscesses,  in  different  strata  of  the  region.  These 
abscesses,  sometimes  enormous,  are  of  a  decidedly  inflam- 
matory type,  sometimes  ultraseptic,  ligneous,  with  emphy- 
sematous gangrene. 

Limited  or  extensive  emphysema  is  an  immediate  com- 


156  WOUNDS  OF  THE  NECK 

plication  of  these  wounds,  likewise  asphyxia  by  laryngo- 
tracheal compression  due  to  effusion  of  blood  or  to  extensive 
emphysema ;  broncho-pneumonia  is  a  later  complication. 

The  prognosis  is  favourable  in  simple  wounds.  It  is  very 
bad  in  those  that  involve  the  large  vessels.  It  is  grave  in 
lesions  of  the  larynx,  the  trachea,  the  laryngo- tracheal  pas- 
sage. The  narrow  wounds  of  the  laryngo-tracheal  passage 
are  perhaps  more  grave  than  the  large  lesions. 

Instant  or  very  rapid  death  occurs  frequently ;  when 
delayed,  the  fatal  ending  is  due  to  haemorrhage  or  to  the 
complications  stated  above,  especially  to  broncho-pneumonia. 

During  the  Hispano- American  War,  out  of  119  wounded 
in  the  neck,  24  died  on  the  battlefield,  and  22  subsequently. 

Treatment. — The  immediate  and  prolonged  treatment  of 
simple  wounds  presents  no  special  indications ;  however,  it 
is  well  to  mention,  with  Professor  Ferraton,  that  the  dress- 
ing must  obtain  support  from  the  forehead  or  in  the  axilla, 
to  avoid  all  chance  of  displacement.  Immobilization  of  the 
head  is  absolutely  necessary. 

To  combat  severe  haemorrhages,  digital  compression 
should  be  applied  to  the  wound,  followed  by  mechanical 
compression  localized  on  the  wound,  exerted  either  through 
the  integument  or  on  the  vessel  itself,  after  it  has  been 
relieved  from  all  constriction.  By  giving  solid  support 
from  the  head  and  from  the  axilla  on  the  same  side,  and  by 
making  the  dressing  very  thick,  we  can  exert  strong  lateral 
compression,  which  at  first  sight  would  seem  to  be  hardly 
bearable.  We  have  noticed  this  again  and  again.  Ferra- 
ton advises  covering  the  dressing  with  a  wooden  or  zinc 
splint  kept  in  place  by  the  spica  bandage  of  the  neck. 

Ligature  of  both  ends  is  the  ideal  treatment,  but  in  its 
application  it  necessitates  coolness  and  all  the  ability  of  a 
skilful  surgeon. 

Wounds  of  the  veins  require  the  same  treatment  as 
those  of  the  arteries. 


TREATMENT  157 

Tracheotomy  should  be  performed  on  men  wounded  in 
the  larynx  and  trachea.  This  must  be  done  at  once ;  it 
must  be  expeditious  and  preventive — that  is  to  say,  it  should 
be  utilized  in  cases  in  which  asphyxia  is  not  threatening, 
and  on  the  first  signs  of  emphysema. 

When  a  pharyngo-oesophageal  wound  is  suspected,  food 
must  no  longer  be  introduced  into  the  mouth ;  we  must 
have  recourse  to  watery  or  nutrient  enemata,  or  to  sub- 
cutaneous injections  of  normal  saline ;  thirst  is  to  be  treated 
by  frequent  rinsing  of  the  mouth. 

Abscesses  should  be  opened,  the  line  of  incision  for 
ligatures  being  followed,  this  being  along  the  anterior 
border  of  the  sterno-mastoid ;  rarely  along  the  posterior 
border  or  in  the  supra-clavicular  space. 


CHAPTER  XV 
WOUNDS  OF  THE  CHEST 

In  the  ambulances  lesions  of  the  chest  represent  an 
average  proportion  of  one  in  ten  or  thirteen  wounded,  but 
a  third  of  these  wounded  have  already  succumbed  on  the 
battlefield,  and  count  among  the  killed ;  at  the  rear  the 
proportion  is  from  6  to  8  per  cent.  (Laurent).  Sometimes  the 
entire  lesion  is  in  the  thorax ;  sometimes  one  of  the  adjoining 
segments  of  the  upper  extremity  is  also  implicated. 

Injuries  of  the  chest  are  divided  into — (i)  Non-penetrating 
wounds,  and  (2)  penetrating  wowids. 

N on- Penetrating  Wounds. 

They  include  wounds  of  the  soft  parts,  and  wounds  of  the 
hones  and  cartilages. 

Among  the  wounds  of  the  soft  tissues  which  resemble  those 
of  all  other  parts,  we  will  only  mention  the  arterial  lesions 
of  the  very  vascular  scapulo-pectoral  region. 

The  bony  injuries  present  the  same  type  as  the  lesions 
of  long  bones  (clavicle,  ribs),  of  spongy  bones  (sternum),  of 
flat  bones  (scapula). 

Clavicle. — On  the  body  of  the  clavicle,  which  is  fre- 
quently injured,  we  see  contusions,  simple  or  with  extensive 
fissures ;  fractures  hy  contact,  either  transverse  or  oblique ; 
grooves  and  perforations,  either  of  the  simple  or  the  com- 
minuted type.    Comminuted  perforations,  the  most  frequent, 

158 


NON-PENETRATING   WOUNDS  159 

have  splinters,  generally  short,  like  those  seen  in  very  com- 
pact Hones.     They  are  nearly  always  adherent. 

The  extremities  of  this  bone  present  lesions  of  the 
epiphysis.  The  relations  of  the  larger  vessels  and  nerves 
in  the  base  of  the  neck  with  the  inner  end  of  the  clavicle, 
and  those  of  the  subclavian  and  axillary  vessels  and  nerves 
with  the  centre  of  the  bone,  render  wounds  of  this  bone 
very  dangerous.  The  wounded  who  present  these  com- 
plications nearly  always  succumb  on  the  battlefield. 
-  Immobilization  is  absolutely  necessary.  It  is  obtained  by 
an  arm-sling,  more  securely  by  bandages  applied  in  the 
manner  advocated  by  Velpeau  or  Desault.  No  exploration 
whatever.  Instances  are  reported  of  simultaneous  fractures 
of  both  clavicles  or  of  the  clavicles  and  sternum. 

Scapula. — The  scapula  is  frequently  injured.  Its  lesions 
belong  to  the  class  of  injuries  of  the  flat  bones  without 
diploe  (the  body),  or  with  diploe  (the  spines,  the  borders). 
They  consist  of  .perforations,  generally  clean,  on  the  body  of 
the  bone,  or  notches  on  its  borders. 

It  is  important  to  consider  the  direction  taken  by  the 
projectile.  When  this  is  antevo -posterior,  the  free  splinters 
are  superficial,  of  easy  access,  and  extrathoracic.  When 
postero-anterior,  the  free  splinters  are  deeply  situated  under 
the  body  of  the  bone,  and  of  difficult  access.  When  trans- 
verse, which  is  the  most  usual,,  the  lesion  is  less  regular 
and  more  complex.  The  bullet,  even  when  it  simply  grazes 
the  bone,  produces  a  fracture  with  numerous  fragments, 
which  are  either  maintained  in  place  or  depressed,  with 
radiating  fissures  or  a  slanting  perforation  (Delorme).  These 
fractures  are  of  the  greatest  gravity. 

Lesions  of  the  acromion  and  the  spine  show  some 
analogy  to  those  of  the  skull ;  they  are  notches,  extensive 
grooves,  clean  perforations,  with  or  without  fissures,  and  free 
splinters  near  the  bony  aperture  of  exit.  As  for  the  coracoid 
process,  it  may  be  notched,  perforated,  or  separated. 


i6o  WOUNDS  OF  THE  CHEST 

Lesions  of  the  scapula  may  give  rise  to  considerable 
haemorrhagic,  oedematous,  or  inflammatory  swelling  of  the 
surrounding  parts. 

Treatment. — No  exploration,  no  immediate  interference 
for  the  removal  of  free  splinters.  Immobilization  of  the 
limb  by  means  of  an  arm-sling  or  bandages. 

Complications. — Haemorrhage,  often  severe,  from  one 
of  the  three  scapular  arteries,  renders  compression,  or  better 
still,  ligature,  necessary.  The  effusion  of  blood  caused  by 
a  wound  of  the  vessels  that  surround  the  scapula  is  some- 
times very  abundant,  and  may  find  its  way  even  down  to 
the  sacrum. 

Suppuration,  in  infected  wounds,  is  to  be  feared  by  reason 
of  its  depth,  its  diffusion  under  the  scapula,  and  because  of 
possible  thoracic  infection.  Formerly  it  contributed  towards 
raising  the  death  ratio  to  12*3  per  cent,  of  these  cases. 
Free  escape  should  be  given  to  the  pus  through  large  peri- 
scapular  incisions. 

Let  us  also  mention  the  presence  of  subscapular  foreign 
bodies,  the  removal  of  which  requires  similar  incisions. 
Foreign  bodies  are  revealed  by  radiography,  sometimes  by 
subscapular  friction  sounds. 

Sternum. — Wounds  of  the  sternum  are  rare ;  they  are 
perforations  with  linear  divisions  of  the  periosteum,  some- 
times erosions  and  furrows. 

Ribs  and  Cartilages. — Unlike  the  other  bones  of  the 
thoracic  wall,  the  ribs  are  seldom  affected  singly,  unless  it 
be  through  tangential  firing  (contusions,  grooves) ;  whereas 
with  bullets  that  penetrate  we  find  notches  with  or  without 
transverse  or  oblique  fracture,  perforations  with  radiating 
fissures  and  splinters,  either  free  or  pushed  onwards,  and 
corresponding  to  the  last  part  of  the  thoracic  wall  through 
which  the  projectile  has  passed. 


PENETRATING   WOUNDS  i6i 

Penetrating  Wounds. 

They  are  frequent.  They  are  seen  in  one-tenth  of  the 
wounded  under  treatment  in  hospitals.  The  most  common 
are  those  with  an  antevo-posteviov  track.  The  surgeon,  by 
calling  on  his  anatomical  knowledge,  can  tell  by  the 
position  of  the  wounds  what  are  the  parts  that  have  been 
injured.  In  the  lower  part  of  the  chest,  from  the  fifth  rib  down- 
wards, the  wound  becomes  thoraco-abdominal. 

Transverse  tracks  are  often  accompanied  by  lesions  of  the 
arm.  These  tracks  should  be  designated  as  postero-anterior, 
vertical  (cervico-thoracic). 

Contoitr  wounds  no  longer  exist.  The  track  followed  by  a 
non-deflected  bullet  is  rectilinear.  A  deflected  or  pivoting 
bullet,  a  round  shrapnel  bullet,  may  make  a  sinuous  and 
irregular  track,  but  never  the  contour  wound  formerly  con- 
sidered classical. 

Simple  penetrating  wounds,  or  wounds  that  implicate  the 
pleura,  are  exceptional.  The  majority  are  penetrating  with 
a  lesion  of  the  lungs  or  heart. 

Wounds  of  the  Lung. 

Penetrating  Wounds  with  Injury  of  the  Lungs. — 

Being  elastic  and  not  very  dense,  the  lungs  usually  present 
pretty  simple  lesions  when  injured  by  bullets  fired  at  point- 
blank  range,  such  as  the  following  :  Fissures,  furrows,  cul-de- 
sac  wounds,  or  total  perforations.  The  aperture  of  entry  is 
circular,  oval,  like  a  slit,  or  narrow  ;  that  of  exit  is  less 
regular.  The  canal  is  not  lacerated,  but  is  slightly  sufl'used 
with  blood  ;  its  walls  adhere. 

The  dimensions  of  the  apertures  and  of  the  track  are  the 
same  as  the  diameter  of  the  projectile  (short  range)  or 
inferior  to  it ;  the  apertures  then  each  look  like  a  small  red 
spot  (3  millimetres).    Remote  fissures  are  seldom  met  with. 

II 


1 62  WOUNDS  OF  THE  CHEST 

A  healthy  king  may  present  a  large  gap  at  the  aperture  of  exit 
of  the  bullet  J  hit  it  does  not  hurst.  There  is  no  explosive 
effect. 

Shrapnel  bullets  form  somewhat  larger  tracks.  The 
aperture  of  entry  is  rounded,  that  of  exit  more  extensive 
and  irregular  (Laurent).  The  sanguineous  trail  that  indi- 
cates the  bullet  track  is  undiscoverable  at  the  end  of  a  week 
(Laurent). 

Diagnosis. — Shock  varies,  sometimes  slight,  "  so  much 
so  that  the  wounded  man  can  continue  to  fight  or  go  on 
foot  to  the  ambulance,  even  if  it  is  at  a  considerable 
distance  "  (Laurent)  ;  sometimes  marked  :  "  The  grave  lesion 
brings  down  the  wounded  man  and  leaves  him  almost 
bloodless  for  several  hours  "  (Laurent). 

Most  of  the  wounded  men  say  they  feel  a  pain  resembling 
the  stroke  of  a  whip.     This  pain  may  be  very  violent. 

Dyspnoea  is  aggravated  by  fractures  of  the  ribs.  Escape 
of  blood  through  the  external  wound,  which  is  rather  rare,  has 
no  particular  signification,  unless  it  is  concomitant  with 
haemoptysis. 

Hemoptysis  is  a  surer  sign.  Slight,  average,  or  excessive, 
it  varies  between  the  spitting  out  of  a  few  sputa,  either 
immediately  or  during  two  or  three  days,  and  the  expectora- 
tion of  a  litre  of  blood  or  more.  In  both  cases  it  is  charac- 
tenstic.  Laurent  has  found  it  in  75  per  cent,  of  the  wounded, 
others  have  noticed  it  in  one-third  of  the  cases.  Issue  of  air 
from  the  wound,  traumatopncea,  emphysema,  are  not  frequent. 
The  same  may  be  said  of  pneumothorax.  Hamoihorax  is 
an  excellent  sign.  Contraction  of  the  abdominal  walls  has 
been  noticed.  Spontaneous  immobilization  of  the  chest  occurs 
habitually.  Lastly,  let  us  recall  one  of  the  most  favourable 
signs — the  connection  of  the  track  with  the  lung. 

The  wounded  zone  should  be  specified  so  far  as  possible : 

(i)  The  peripheral  zone,  the  small  vessels  and  the  bron- 
chioles being  the  only  parts  affected.     (2)  The  middle  zone 


WOUNDS  OF  THE  LUNG  163 

with  vessels  and  bronchi  of  medium  size.  (3)  The  central 
zone,  region  of  the  hilum  and  of  the  larger  bronchi. 

Wounds  of  the  middle  zone  present  the  plainest  symptoms, 
and  the  ones  most  usually  observed  ;  those  of  the  hilum  are 
the  worst. 

Complications. — Hc^mothorax  is  the  most  serious  primary 
complication  in  wounds  of  the  chest.  It  is  often  con- 
comitant with  partial  pneumothorax.  Variable  as  to  the 
rapidity  of  its  course  and  the  abundance  of  its  contents, 
it  may  entail  the  death  of  the  wounded  man,  or  else  throw 
him  into  the  gravest  state  of  acute  anaemia,  or  finally  it  may 
be  found  compatible  with  life. 

It  is  reabsorbed  in  the  majority  of  cases  treated  by  the 
surgeon.  The  wound  would  be  exposed  to  infection  if 
interfered  with  under  precarious  conditions.  Pneimonia  is 
exceptional. 

Pleurisy  is  a  frequent  consecutive  complication.  It  is 
adhesive,  serous,  or  purulent.  A  large  thoracic  wound, 
infection  through  fragments  of  clothing,  large  haemothorax, 
favour  its  appearance.  It  accounts  for  the  fever  of 
the  wounded  man.  Its  treatment,  which  here  offers  nothing 
special,  is  one  of  the  most  active  amongst  those  for  wounds 
of  the  chest  by  projectiles. 

Hernia  of  the  lung  is  very  rare  ;  extensive  emphysema  is 
exceptional ;  foreign  bodies  (splinters,  bullets,  fragments  of 
clothing)  are  pretty  frequently  noticed.  Metallic  foreign 
bodies  have  a  tendency  to  find  their  way  into  the  pleural 
cul-de-sac. 

Treatment. — It  is  simple,  and  carries  out  the  following 
indications : 

(i)  Rest  for  the  wounded  man.  (2)  Application  oj  dressings, 
with  occlusion  of  the  wounds.  (3)  Immobilization  of  the  thorax. 
(4)  Treatment  of  complications.  No  extensive  surgical  intervention 
is  to  be  undertaken, 

I.  At  the  shelters  for   the  wounded  ;  at   the  relief  and 


1 64  WOUNDS  OF  THE  CHEST 

first  aid  station ;  at  the  ambulance  :  Rest  in  a  supine  or 
sitting  position. 

The  wounded  must  be  raised  with  the  greatest  care,  to 
avoid  syncope,  cough,  pain,  detachment  of  clots. 

When  they  present  lesions  of  the  central  zone,  the  wounded  must 
not  he  sent  hack  to  the  rear.  Their  transport  should  be  effected 
as  much  as  possible  on  stretchers,  and  should  be  strictly 
limited  to  the  distance  necessary  to  take  them  to  the  nearest 
ambulance. 

Transporting  to  a  distance  makes  the  prognosis  much 
more  serious.  Against  pain  and  dyspncea,  injection  of 
morphine. 

2.  Dressing. — It  must  be  occhtsive,  without  suture.  Occlusive 
to  prevent  the  access  of  the  external  air,  but  not  enough  to 
hinder  the  exit  of  the  intrathoracic  air.  Thus  emphysema 
is  prevented.  We  must  be  careful  not  to  introduce  drains 
into  the  wounds  ;  their  use  gave  rise  to  deplorable  results 
during  the  Balkan  War.  We  should  abstain  from  suturing 
either  direct  or  instrumental. 

After  touching  the  wound  and  its  immediate  vicinity  with 
tincture  of  iodine  (only  once),  the  dressing  is  appHed.  It 
must  he  very  large,  covered  with  cotton-wool,  and  should 
include  the  whole  thorax  and  even,  according  to  the  seat  of 
the  wound,  the  adjoining  regions,  the  abdomen,  the  neck. 

3.  The  dressing,  firmly  maintained  by  a  body  bandage, 
will  secure  immohilization  of  the  thorax.  Loosening  of  the 
dressing  will  be  prevented  by  more  bandages.  This  dress- 
ing is  to  be  preferred  to  bands  of  sticking-plaster  applied 
round  the  thorax  over  aseptic  gauze. 

4.  It  is  chiefly  in  serious  cases  that  the  application  of 
the  above-mentioned  methods  of  treatment  should  be 
very  complete. 

In  cases  presenting  a  grave  general  state,  especially 
when  it  is  connected  with  haemothorax,  we  must  make  a 
point,  according  to  the  case,  of  administering  anodynes,  of 


WOUNDS  OF  THE  LUNG  165 

givin_g  injections  of  morphine,  making  the  patient  keep, 
so  far  as  possible,  the  semi-recumbent  position,  or  at  least 
a  lateral  one  on  the  injured  side.  We  must  also  have 
recourse  to  alcoholic  stimulants,  to  cardiac  tonics  (ether, 
caffeine,  camphorated  oil),  to  injections  of  adrenalin,  chloride 
of  calcium,  normal  saline,  to  circular  ligation  of  the  limbs 
at  their  proximal  end  in  order  to  secure  venous  stasis. 

If  asphyxia  is  threatening,  we  should  aspirate,  which 
must  be  repeated  if  necessary ;  but  as  a  general  rule  it  is 
best  not  to  meddle  with  haemothorax.  It  insures  a  salutary 
compression.  Aspiration  should  not  be  carried  out  till 
after  the  first  twenty-four  or  forty-eight  hours. 

Although  we  advocate  great  extensive  interventions  in 
those  cases  of  very  severe  intra-  or  extra-thoracic  haemor- 
rhage we  see  in  civil  practice,  we  have  always  been 
opposed  to  them  in  ambulance  work.  They  would  be  neither 
opportune  nor  wise,  for  reasons  we  cannot  here  develop. 
Even  in  extreme  cases  one  m,ust  abstain  from  any  big  operation. 

Pleurisy,  which,  we  repeat,  is  frequent,  calls  for  puncture 
at  first,  then  for  the  operation  for  empyema,  so  soon  as  the 
pus  is  revealed  by  the  Pravaz  syringe.  This  operation  is 
one  of  the  triumphs  of  thoracic  surgery  in  these  cases. 
When  done  early,  it  insures  rapid  recovery.  No  washing 
out  is  necessary  ;  large  dressings  renewed  at  frequent 
intervals  ;  no  portions  of  rib  resected  (Laurent),  for  the 
tendency  towards  rapid  recovery  is  here  strongly  marked. 

In  very  extensive  wounds,  the  result  of  shell  splinters, 
hernia  of  the  lung  may  necessitate,  according  to  cases, 
reduction  or  ligature.  Against  generalized  emphysema  we 
should  employ  a  large  incision  of  the  tissues  as  far  as  the 
muscular  wall,  or  overlapping  circular  incisions. 

The  extraction  of  the  foreign  bodies  will  be  done  subse- 
quently through  a  sloping  incision. 

In  thoraco-abdominal  wounds  the  abdominal  lesion  dominates, 
and  abstention  is  our  line  of  conduct. 


1 66  WOUNDS  OF  THE  HEART 

Prognosis. — Thus  treated,  and  without  being  transported, 
men  wounded  in  the  chest  recover  rapidly  and  completely 
when  primarily  the  wound  has  not  been  of  very  great 
severity.  A  very  large  number  of  thoracic  bullet  wounds 
surprise  us  by  their  extreme  benignity.  This  is  because 
the  pulmonary  wound  is  narrow,  not  complicated  by  the 
presence  of  foreign  bodies  (make  certain  by  inspection  of 
the  clothes  that  there  is  no  loss  of  substance  from  them), 
and  without  notable  haemorrhage,  the  lung  wound  being 
peripheral. 

WOUNDS  OF  THE  HEART. 

They  are  never,  so  to  speak,  met  with  in  the  ambulances 
(Laurent) ;  the  same  may  be  said  of  wounds  of  the  large 
vessels.  The  great  interest  with  which  the  former  are 
regarded  in  daily  practice,  by  reason  of  the  brilliant  opera- 
tions they  give  rise  to,  ceases  to  exist  in  war  surgery.  In 
our  sanitary  formations  abstention  must  be  the  rule,  because 
of  the  risks  in  surgical  interference,  the  dangers  of  infec- 
tion, etc. 

In  the  very  rarest  contingencies  only  an  exception  to  this 
rule  may  exist,  therefore  we  will  simply  pause  an  instant 
to  state  that  the  heart,  when  wounded  by  bullets  fired 
from  a  short  range,  has  sustained  explosive  effects  ;  when 
the  bullets  are  from  other  distances,  it  is  eroded  or 
perforated. 

Expectation  is  the  line  of  conduct  to  follow :  it  includes 
absolutely  perfect  rest,  absence  of  all  excitement,  the  use  of 
morphine,  and  immobilization  of  the  chest. 


CHAPTER  XVI 
WOUNDS  OF  THE  ABDOMEN 

Counting  deaths  on  the  battlefield,  the  percentage  of 
wounds  of  the  abdomen,  according  to  Ferraton,  is  13  or 
14.  That  of  the  wounded  received  in  the  ambulances 
fluctuates  between  7  and  10  ;  a  very  small  number  of 
these  cases  are  transported  to  the  base  hospitals. 

The  proportion  of  penetrating  wounds  is  50  per  cent. 
These  statistics,  which  are  partly  of  ancient  date,  require 
revising  and  completing. 

The  claims  of  diagnosis,  and  also  those  of  categorical 
statistics,  have  already  made  an  exact  knowledge  of  the 
abdominal  regions  absolutely  necessary  to  the  surgeon ;  on 
the  other  hand,  the  relations  the  external  orifices  of  the 
wounds  bear  to  these  regions  constitute  indications  of  the 
highest  value,  in  spite  of  the  displacements  which,  through 
respiratory  movements  or  change  in  the  position  of  the 
body,  certain  movable  organs  may  undergo. 

In  planning  out  the  abdomen,  we  divide  it  into  three  stories 
one  above  the  other  :  the  first  or  superior  is  situated  between 
the  diaphragm,  the  dome  of  which  corresponds  with  a 
horizontal  line  passing  through  the  fifth  rib,  and  another 
line,  also  horizontal,  which  just  touches  the  thoracic  brim. 

The  second  or  middle  is  contained  between  this  last- 
mentioned  line  and  the  horizontal  plane  between  the  two 
anterior  superior  iliac  spines. 

167 


i68 


WOUNDS  OF  THE  ABDOMEN 


The  third  or  infeviov  is  situated  below  the  iliac  plane  just 
mentioned,  thus  corresponding  to  the  pelvis. 

The  upper  space  is  thoraco-ahdoininal. 

Two  vertical  lines  starting  from  the  centre  of  Poupart's 
ligament  divide  this  space  into  three  secondary  zones  :  the 
right  hypochondrium,  the  epigastric,  in  the  centre^  the  left 
hypochondriitm  ;  these  lines  also  divide  the  middle  abdominal 
space  into  two  lateral  regions,  the  right  and  left  lumbar,  with 
the  umbilical  in  the  centre  and  finally  divide  the  inferior 
story  into  right  and  left  iliac  and  hypogastric  in  the  centre. 
The  following  table  shows  the  organs  contained  in  each  of 
these  nine  regions  : 


Right  Hypochon- 
drium. 

Cul  -  de  -  sac   of    the 

pleura. 
Diaphragm. 
Liver,    biliary  ducts, 

portal  and  inferior 

cava  veins. 


Right  Lumbar. 

Ascending  colon,  he- 
patic flexure,  hid- 
den under  the  liver. 

Duodenum. 

Right  lumbar  fossa. 


Right  Iliac. 

Caecum. 
Iliac  vessels. 
Anterior  crural  nerve. 
Pelvis. 


Epigastric. 

Stomach. 
Pancreas. 
The    great   omentum 

(posterior  cavity). 
Left  lobe  of  the  liver. 
Cceliac  axis. 
Aorta. 
Vertebral  column. 

Umbilical. 

Stomach,    when   dis- 
tended. 
Great  omentum. 
Mesentery. 
Small  intestines. 
Transverse  colon. 
Aorta. 

Inferior  vena  cava. 
Vertebral  column. 

Hypogastric. 

Cavity  of  Retzius. 

Bladder,  when  full. 

Rectum. 

Aorta. 

Inferior  vena  cava. 

Vertebral  column. 

Sacrum. 


Left  Hypochon- 
drium. 

Thorax  and  pleura. 

Spleen. 

Left  kidney. 


Left  Lumbar. 
Descending  colon. 


Soft  Iliac. 

Sigmoid  flexure. 
Iliac  vessels. 
Anterior  crural  nerve. 
Pelvis. 


Antero-posterior  tracks,    by  far   the  most  common,  often 
affect  but  one  region  ;  transverse  cracks  go  through  several 


PENETRATING  WOUNDS  169 

regions,  either  horizontally  or  obliquely.      Vertical  tracks 
are  rare. 

Cold  Steel  Wounds. — These  are  deep,  though  they  do  not 
always  wound  the  intestines  (bayonet,  lance),  and  superficial 
(cutting  weapons). 

Non-Penetrating  Wounds. 

Contusions,  cul-de-sac  wounds,  parietal  perforations,  may  be 
seen  on  the  abdominal  wall.  In  tangential  firing  the  furrow 
or  the  seton  made  by  the  bullet  is  sometimes  very  extensive. 
Fragments  of  large  projectiles  make  on  the  abdomen  furrows 
or  setons,  especially  very  long  furrows. 

Penetrating  Wounds. 

Simple  penetrating  wounds  are  exceptional.  A  bullet 
that  goes  through  the  wall  produces  always,  so  to  speak,  a 
penetrating  wound  with  a  visceral  lesion. 

Lesions  of  the  Intestine. — In  the  small  intestine,  which 
is  the  more  often  wounded,  and  whose  lesions  may  be 
regarded  as  types  of  wounds  of  hollow  organs,  we  see 
contusions,  tearing,  or  perforations.  Perforations  are  very 
common  ;  they  are  multiple  in  the  intestine,  frequently  four 
in  number,  but  as  many  as  thirty  have  been  seen.  They 
are  generally  most  numerous  from  transverse  firing.  The 
lesions  are  less  from  bullets  which  have  but  a  small  velocity ; 
they  increase  in  size  with  average  velocity  and  more  especi- 
ally with  great  velocity  ;  this  is  an  important  fact.  Their 
size  is  in  proportion  to  the  calibre  of  the  bullets,  therefore 
they  are  larger  when  caused  by  shrapnel  bullets  or  shell 
fragments  than  by  ordinary  modern  bullets.  They  increase 
in  size  with  flattened  bullets,  but  they  become  much  smaller 
with  pointed  bullets,  whose  wound  resembles  a  puncture. 

The  orifices  of  the  perforations  are  circular  or  oval,  some- 
times almost  like  a  mere  slit,  punctiform,  and  more  often 


170  WOUNDS  OF  THE  ABDOMEN 

with  loss  of  substance.  The  aperture  of  entry  looks  as  if  it 
had  been  punched  out,  and  gapes  ;  the  aperture  of  exit  is 
everted,  with  the  mucous  membrane  bulging,  and  is  often 
larger  than  the  aperture  of  entry.  Sometimes  the  two  orifices 
are  quite  near  to  one  another,  and  only  separated  by  a 
little  bridge  ;  more  often,  however,  they  are  wide  apart. 

1.  At  a  greater  distance  than  400  metres,  the  present  bullets 
of  small  calibre  generally  leave  very  small  perforations,  which 
might  almost  be  called  simple  punctures  ;  they  have  a  great 
tendency  to  close  up  spontaneously  (Ferraton).  Through 
these  orifices,  when  they  are  larger  than  simple  punctures, 
the  mucous  membrane  is  pushed  out  like  a  hernia ;  and  it 
prevents  to  a  certain  extent  the  egress  of  solid  or  liquid 
intestinal  material,  but  not  that  of  gas.  The  contraction  of 
the  peripheral  muscular  fibres  narrows  the  openings  ;  when 
the  contraction  ceases,  the  localized  inertia  of  the  intestine 
prevents  the  escape  of  fluids. 

2.  When  the  bullet  has  been  fired  from  a  less  distance  than 
400  metres,  when  it  has  struck  obliquely,  and  has  under- 
gone a  deviation  before  reaching  the  intestine,  when  the  pro- 
jectile is  a  shrapnel  bullet  and  a  fortiori  a  shell  fragment,  the 
intestinal  orifices  are  like  the  cutaneous  orifices,  the  latter  show- 
ing the  extent  de  visu  of  the  former,  but  larger  and  less  likely 
to  be  closed  by  the  mucous  membrane.  The  stercoraceous 
effusion  is  then  more  abundant,  more  continuous  than  in 
the  first  case^  in  which  it  may  be  very  small,  especially  if 
the  wounded  man  was  fasting. 

A  t  very  short  distances  we  see  explosive  effects :  bursting 
of  the  intestine,  large  gaping  wounds,  especially  if  the 
bowel  was  full  at  the  time  of  the  wounding ;  nevertheless, 
severe  disturbance,  owing  to  pointed  bullets,  is  less  com- 
mon than  formerly.  They  would  be  frequent  with  bullets 
having  a  blunt  extremity  (Austrian  and  Russian).  Con- 
tused sections  are  very  exceptional  (shell  fragments). 

These  typical  lesions  of  the  small  intestine  are  also  seen 


PENETRATING  WOUNDS  17^ 

in  the  large  intestine.  The  large  bowel  is  more  vulner- 
able because  it  is  fixed ;  but  its  perforations  are  less  grave 
by  reason  of  the  solid  nature  of  its  contents  and  the 
absence  of  mobility,  which  prevents  dissemination  of  con- 
taminating products. 

The  same  lesions  are  also  seen  in  the  stomach,  the 
rectum,  the  bladder,  and  the  gall-bladder. 

In  the  stomach,  whose  walls  are  thicker  than  those  of 
the  small  intestine,  perforations  are  generally  narrower, 
and  with  more  tendency  to  close  spontaneously.  The 
vascularity  of  the  organ  makes  the  patient  liable  to  intra- 
peritoneal haemorrhage  or  to  hsematemesis. 

The  perforations  are  generally  double,  and  involve  at  the 
same  time  the  anterior  and  the  posterior  wall  (effusion 
easily  taking  place  into  the  large  peritoneal  cavity  or  into  the 
posterior  cavity  of  the  omenta).  Like  the  intestinal  walls, 
the  wall  of  the  stomach  may  be  contused  or  grazed. 

The  liver  presents  the  typical  lesions  of  abdominal 
parenchymatous  viscera.  They  consist  of  contusions 
(exceptional  with  rifle  bullets,  more  frequent  with  shrapnel 
huWeis),  fiirrows  and  grooves  scooped  out  on  the  surface,  cul- 
de-sac  wounds,  or  total  perforations. 

The  orifices  and  the  tracks  made  by  the  bullets  are 
generally  narrow,  rounded,  not  gaping,  but  prolonged  by 
fissures  whose  depth,  extent,  and  number  are  connected  with 
the  velocity  of  the  bullet.  These  fissures  are  all  the  more 
numerous  and  deep  the  greater  in  general  the  velocity— 
that  is  to  say,  the  nearer  the  firing. 

From  a  short  distance  we  see  explosive  effects,  with  numerous 
subdivisions,  both  locally  and  at  a  distance,  the  apertures  of 
exit  much  enlarged,  gaping,  and  bleeding.  The  liver  being 
a  very  vascular  organ,  it  bleeds  copiously. 

In  the  spleen,  which  is  just  as  vascular,  the  orifices  and 
tracks  are  in  general  larger  than  in  the  liver,  and  more 
complicated,  with  extensive  fissures. 


172  WOUNDS  OF  THE  ABDOMEN 

The  pancreas,  whose  traumatisms  may  be  complicated 
by  lesions  of  the  stomach,  the  duodenum,  the  liver,  etc., 
presents  wounds  analogous  to  those  of  the  liver,  though  less 
severe  by  reason  of  the  greater  solidity  of  the  pancreas. 

To  sum  up,  the  principal  cause  of  the  gravity  of  abdomi- 
nal penetrating  wounds  by  projectiles  is  the  frequency  and 
copiousness  of  the  immediate  effusion,  the  vast  effusion  of 
blood  furnished  by  the  parenchymatous  organs  and  the 
large  vessels,  but  also,  in  addition,  by  vessels  of  the  second 
and  third  class,  from  which  the  haemorrhage,  though  not  so 
sudden,  is  none  the  less  grave  by  reason  of  its  persistence  ; 
and,  again,  there  are  the  pourings  out  of  food  and  secretions, 
both  irritating  and  septic,  giving  rise  to  the  very  gravest  local 
or  general  reaction,  to  peritonitis. 

Poured  out  in  large  quantities,  the  blood,  aided  by 
gravity,  invades  the  lower  parts  of  the  body,  the  flanks, 
the  exterior  of  the  colons,  or  more  often  the  iliac  fossae  and 
the  true  pelvis.  The  effusion  on  the  right  side  penetrates 
directly  into  the  right  iliac  fossa ;  on  the  left  side  it 
descends  into  the  left  iliac  fossa  and  into  the  true  pelvis. 

When  less  abundant,  the  effusion,  instead  of  filling  the 
peritoneum,  may  accumulate  as  a  collection  of  pockets  in 
the  neighbourhood  of  the  lesion  in  the  wounded  viscus. 

The  mixture  of  the  blood  with  the  septic  products  of  the 
hollow  organs  gives  rise  rapidly  either  to  the  formation  of 
adhesions,  or  to  septic  or  purulent  peritoneal  effusions, 
sometimes  circumscribed  in  the  vicinity  of  the  visceral 
lesion,  sometimes  multiple,  sometimes  generalized. 

Peritonitis  is  the  great  danger  in  these  wounds,  and  the 
higher  the  lesion  the  greater  the  risk  of  this  complication. 
A  well-known  fact  is  that  the  power  of  absorption  of  the 
peritoneum  is  specially  marked  in  the  superior  peritoneum 
above  the  transverse  colon,  and  that  it  is  reduced  to  a 
minimum  at  the  level  of  the  inferior  peritoneum  and  in  the 
true  pelvis. 


PENETRATING  WOUNDS  173 

Diagnosis. — Although  the  symptoms  of  the  traumatisms 
of  the  abdomen  by  the  weapons  of  warfare  are  in  a  great 
degree  like  those  we  observe  in  similar  lesions  of  ordinary 
practice,  it  may  be  as  well  to  call  to  mind  their  chief 
differential  characteristics. 

Shock,  pain  (rarely  acute),  dyspnoea,  nausea,  vomiting, 
are  all  often  absent ;  a  small  ptilse  is  unreliable  at  first ; 
disappearance  of  the  liver  dulness  is  a  valuable  symptom,  but  it 
is  very  variable,  as  also  is  dulness  in  the  iliac  fossa. 

Escape  of  blood  through  the  anus  is  a  late  symptom,  and 
subcutaneous  emphysema  is  rare.  Primary  diagnosis  is  based, 
in  short,  on  rigidity  of  the  abdominal  walls,  a  wooden  feeling  0} 
the  abdomen,  absence  of  abdominal  respiration,  finally,  by  the 
relations  of  the  external  perforating  wounds  to  the  regions  of  the 
abdomen.  We  can  assert  that  these  lesions  are  always  per- 
forating under  normal  conditions  of  fire  ;  therefore,  if  we 
cannot  feel  the  projectile  in  the  abdominal  wall,  we  can  prac- 
tically say  that  a  track  exists  in  the  abdomen  formed  by 
the  projectile,  and  we  therefore  diagnose  a  perforating 
wound. 

HcBmorrhage  is  revealed  by  signs  of  acute  ancemia  and  by 
the  discovery  of  rapid  effusion  into  the  iliac  fossce. 

Peritoneal  reaction,  nearly  always  fatal  after  penetrating 
wounds^  shows  itself  especially  hy  peritoneal  fades,  dissociation 
of  the  pulse  and  temperature,  inguinal  or  rectal  tenderness,  vesical 
tenesmus. 

HcBmatemesis  would  indicate  a  lesion  of  the  stomach,  but 
it  is  a  rare  sign  ;  radiating  pains  in  the  right  or  left  shoulder  are 
the  only  indirect  signs  to  remember  amongst  those  that  are 
given  for  the  diagnosis  of  lesions  of  the  spleen  and  of  the 
liver,  iox  jaundice  and  escape  of  bile  through  a  narrow  wound 
are  uncommon,  and  escape  of  splenic  stibstance  through  the 
wound  or  hernia  of  the  viscus  are  only  seen  in  large  wounds 
produced  by  shell  splinters. 

To  sum  up,  a  localized  diagnosis,  often  very  uncertain, 


174  WOUNDS  OF  THE  ABDOMEN 

can  only  be  guaranteed  by  proving  the  relations  of  the 
track  to  the  different  organs  of  the  abdomen. 

Course  of  the  Case. —  Aseptic  evolution  oi  penetrating 
wounds  of  the  abdomen,  even  when  intestinal  lesions  are 
present,  has  become  less  exceptional  since  the  adoption 
of  bullets  having  a  small  calibre  and  a  pointed  extremity, 
and  cases  with  limited  septic  evolution  and  circumscribed 
peritonitis  have  also  become  more  frequent.  Peritoneal 
reaction,  which  has  ended  in  an  abscess,  then  remains 
more  or  less  localized  all  around  the  visceral  perforations ; 
it  is  confined  to  one  of  the  abdominal  divisions  or  to  one 
side  of  the  abdomen,  above  or  below  the  transverse  meso- 
colon, to  the  right  or  to  the  left  of  the  mesentery.  Un- 
fortunately, far  too  frequent,  almost  habitual,  is  the  diffuse, 
generalized,  suppurative,  or  ultra-septic  peritonitis,  in  the 
form  of  peritoneal  septicaemia  and  super-acute  intoxication, 
with  hypothermia,  dissociation  of  the  pulse  and  the  tem- 
perature, thready  pulse,  inert  belly,  tympanites,  abdominal 
facies,  vomiting — first  bilious,  then  fecaloid — scanty  urine, 
general  depression,  but  without  loss  of  intelligence.  All 
these  symptoms  demonstrate  the  gravity  of  this  compli- 
cation. 

Foreign  bodies  derived  from  the  clothing  pushed  for- 
wards by  deflected  bullets,  shrapnel  bullets,  or  fragments 
of  large  projectiles,  contribute  on  their  side  to  peritoneal 
infection.  Metallic  foreign  bodies  in  themselves  are  a  very 
small  complication,  and  their  presence  would  at  first  have 
no  influence  on  the  treatment.  We  must  avoid  all  attempts  at 
immediate  removal.  We  will  only  mention,  in  order  that  it 
be  remembered,  their  escape  after  ulceration  of  the  hollow 
viscera. 

Prognosis. — Immediate  death  is  less  frequently  the  sequel 
of  penetrating  wounds  of  the  abdomen  than  that  of  lesions  of 
the  skull  or  of  the  thorax,  for  it  has  been  noted  only  in  an 
oscillating  proportion  of  one-half  and  one-fifth  of  the  fatal 


PENETRATING   WOUNDS  175 

cases  on  the  battlefield  (shock,  haemorrhage);  but  this  is 
but  a  deceptive  point  of  view  in  reference  to  their  gravity. 
Another  fifth  of  these  patients  die  vapidly  in  a  few  hours 
in  the  fixed  or  movable  ambulances,  and  definite  cure,  as 
yet  but  badly  shown  by  statistics  with  regard  to  the  trau- 
matisms caused  by  the  present  projectiles,  is  probably  not 
seen  in  a  half  of  the  remainder.  However,  one  fact  stands 
out  clearly — that  the  excessive  mortality  (92  in  100, 
Crimea;  80  to  90  per  cent.,  War  of  Secession;  50  to 
70  per  cent,  Russo-Japanese  War;  40  to  50  per  cent., 
South  Africa)  diminishes  as  the  calibre  of  the  bullets  become 
smaller  and  as  treatment  is  better  understood. 

But  this  is  not  enough.  These  traumatisms  are  still  too 
grave ;  therefore  wounds  of  the  abdomen  are  those  that  should 
derive  the  greatest  benefit  from  treatment  in  this  war.  The  results 
obtained,  and  the  nature  of  the  traumatisms,  which  is  at 
present  less  formidable  (pointed  bullets),  will  help  the 
surgeon  to  attain  this  object. 

The  relatively  benign  nature  of  a  penetrating  wound  of  the 
abdomen  by  a  bullet  is  largely  connected  with  the  diameter 
and  the  active  force  of  the  bullet — that  is  to  say,  with  the  size 
of  the  intestinal  wounds.  The  greater  the  range  and  the 
smaller  the  diameter  of  the  projectile,  the  more  the  per- 
forations are  reduced  in  size.  The  extent  of  the  intestinal 
wounds  is  related  to  that  of  the  external  wounds,  which  last  serve 
as  indications  to  us. 

Wounds  with  large  orifices  made  by  deflected  bullets,  by 
bullets  that  have  turned  over  in  their  course,  by  shrapnel 
bullets,  by  large  shell  fragments,  are  always  the  most  severe, 
and  at  a  range  of  less  than  400  metres  it  is  to  be  feared 
that  the  S  and  D  bullets  present  the  same  gravity. 

The  lesions  being  equal,  the  prognosis  of  wotmds  of  the 
small  intestine  is  the  most  grave  (immediate  and  abundant  ster- 
coraceous  suffusion).  This  prognosis  becomes  less  serious 
with  wounds  of  the  stomach,  and  still  less  with  those  of  the 


176      WOUNDS  OF  THE  ABDOMEN 

large  intestine,  with  the  exception  of  the  transverse  colon, 
and,  finally,  still  less  with  lesions  of  the  rectum.  Wounds 
of  parenchymatous  organs  are  less  grave  than  those  of 
hollow  organs,  and  in  order  of  their  gravity  we  may  mention 
the  liver,  the  spleen,  and  finally  the  kidneys  ;  and  here 
again  the  question  of  active  force  and  length  of  range 
comes  into  play.  At  reduced  distances  the  tracks  are 
wider,  more  gaping,  more  fissured,  more  likely  to  furnish  a 
haemorrhage  which  is  formidable,  on  account  of  its  abun- 
dance and  its  persistence. 

A  hsolute  immobility  is  an  important  factor  in  making  the  prog- 
nosis less  tinfavourahle.  It  is  one  of  the  best.  In  the  Transvaal, 
at  Spion  Kop,  all  the  wounded,  being  in  a  mountainous 
country,  and  having  necessarily  to  be  transported  over 
very  rough  ground,  succumbed ;  at  Jacobsthal  a  great 
many  men  who  were  not  moved  recovered.  We  have  seen 
quite  a  series  of  wounded  cured  by  expectation,  the  soldiers 
having  been  obHged  to  remain  on  the  field  of  battle  for 
several  days  without  being  able  to  move  from  one  spot, 
with  nothing  to  drink  or  to  eat. 

Treatment. — The  treatment  of  penetrating  wounds  of 
the  abdomen  during  a  campaign  has  passed  through  three 
different  phases — an  old  one,  the  expectant ;  an  active 
one,  extensive  and  early  laparotomy ;  a  third,  the  one 
of  the  present  period,  expectant,  brought  forward  at 
first  as  a  theory  (Delorme,  Chavasse,  Haga,  etc.),  then 
confirmed  by  experience  acquired  in  warfare.  May  the 
present  war  bring  to  light  a  fourth  phase,  in  which  treat- 
ment, more  unvarying,  more  susceptible  of  generalization, 
and  formations  better  adapted  to  circumstances  and  to 
the  great  variety  of  the  lesions,  will  contribute  to  lower  a 
mortality  that  is  still  excessive. 

With  regard  to  the  treatment  of  perforating  wounds,  we 
will  reproduce  almost  in  full  what  we  have  already  said  in 
our  "  Advice  to  Surgeons." 


PENETRATING   WOUNDS  177 

Treatment  of  wounds  of  the  abdomen^  with  lesion  of  the 
intestine,  merits  the  undivided  attention  of  surgeons, 
especially  of  the  surgeons  at  the  front.  The  treatment  has 
been  enriched  by  new  methods,  as  yet  not  sufficiently  known, 
the  use  of  which  will  contribute  to  the  lowering  of  the 
invariably  dark  prognosis  of  these  wounds. 

If  we  discuss  the  opportunities  for  extensive  laparotomy  in 
wounds  of  the  abdomen  and  intestines  in  ordinary  everyday 
practice,  we  find  they  are  not  at  all  the  same  in  war 
surgery.  As  a  principle,  immediate  laparotomy  should  be 
rejected.  The  most  recent  wars — Transvaal,  Manchuria, 
Balkan — have  shown  its  harmfulness. 

In  the  Transvaal,  although  performed  by  eminent  sur- 
geons, under  the  best  conditions  for  its  success,  it  furnished 
many  less  cases  of  cure  than  did  absolute  abstention  from 
operative  interference,  so  much  so  that  MacCormac  was 
able  to  say :  "  A  man  wounded  in  the  abdomen  dies  if 
operated  upon  ;  he  lives  if  left  alone." 

During  the  Russo-Japanese  War,  on  the  Russian  side, 
laparotomy  was  abandoned  because  of  its  want  of  success 
(95  per  cent.) ;  on  the  Japanese  side  it  had  to  be  forbidden. 
After  the  Italian-Turkish  War  (19 12)  it  was  condemned, 
and  also  in  the  French  campaign  in  Morocco. 

On  the  other  hand,  mortality  consecutive  to  operative 
abstention  fell  from  87  per  cent,  during  the  War  of  Secession 
to  50  per  cent.  Its  mortality  oscillates  between  one-half 
and  one-third. 

Delay  in  the   patient's   arrival,  difficulty  of  finding  an 

aseptic  centre,  length  of  operation,  the  absolute  necessity 

of  treating  simultaneously  hundreds  of  wounded  men  all 

arriving   at   the   same   time,   etc.,   are,  together   with   the 

operative  mortality,  the  principal  and  valid  reasons  for  the 

rejection  of  extensive  laparotomy,  which  should  be  considered 

as  only  an  exceptional  method. 

12 


178      WOUNDS  OF  THE  ABDOMEN 

From  the  point  of  view  of  treatment,  we  have  divided 
these  wounded  into  two  groups — those  with  narrow  wounds, 
those  with  extensive  wounds  (Delorme)."^ 

1.  Narrow  Wounds. — As  we  have  already  seen,  the  German 
bullet,  striking  the  abdomen  point-hlank,  especially  at  long 
and  medium  ranges,  makes  in  the  abdominal  wall  a  narroiv 
aperture  of  entry,  and  does  not  carry  with  it  infecting  foreign 
bodies  derived  from  the  clothes.  In  the  intestinal  coils  it 
only  produces  little  orifices — very  small  perforations  that 
have  a  tendency  to  close  up  spontaneously.  Even  in  some 
cases  it  insinuates  itself  between  the  coils  without  perforating 
them.  The  immediate  and  valuable  instinctive  evacuation 
of  both  the  intestine  and  the  bladder,  the  fact  of  the  wounded 
man  remaining  for  hours  on  the  same  spot  without  ex- 
periencing the  shock  of  transport,  all  these  conditions  pre- 
vent intraperitoneal  suffusion,  or,  at  any  rate,  circumscribe 
it,  and  promote  recovery. 

In  this  category  of  traumatisms  the  old  treatment  seems 
to  suffice  :  absolute  rest,  no  transporting  to  a  distance,  com- 
plete deprivation  of  food,  and  especially  of  drink,  for  several 
days — a  regimen  well  borne,  thanks  to  incessant  rinsing 
of  the  mouth,  rectal  and  intracellular  injections  of  normal 
saline,  finally  to  opium  and  Fowler's  position. 

2.  Extensive  Wounds. — When,  on  the  other  hand,  the 
velocity  of  the  projectile  has  been  greater,  the  bullet  has 
turned  over  in  its  course,  or,  in  cases  struck  by  shrapnel 
bullets,  the  circular  or  oval  aperture  of  entry  in  the  skin  is  bigger, 
the  wounds  also,  as  well  as  the  intestinal  lesions,  are  larger, 
and  are  less  likely  to  become  spontaneously  obliterated ; 
and  complications  resulting  from  shreds  of  clothing  are 
frequent. 

In  these  cases  peritoneal   infection   is  certain,  but  the 

*  Delorme,  "On  Wounds  in  War:  Advice  to  Surgeons."  Paper 
read  at  the  Institute,  August  10,  1914. 


PENETRATING   WOUNDS  179 

surgeon  is  by  no  means  disarmed.  To  the  treatment  already 
indicated  he  can  add,  if  possible,  the  continuous  drop  by 
drop  rectal  instillations  of  Murphy,  especially  the  Murphy's 
quick  incision  and  drainage,  and  copious  washing  out  of  the 
peritoneum  with  ether  (Souligoux). 

Murphy's  incision,  that  Professor  Ferraton  has  highly 
recommended  -  in  France,  consists  of  a  small  button-hole 
cut  made  in  the  abdominal  wall  above  the  pubic  arch. 
Through  this  incision,  done  at  an  early  period  under  simple 
local  anaesthesia  after  a  rapid  disinfection  of  the  skin  by 
iodine,  the  cavity  of  the  pelvis  is  drained,  and  here,  thanks 
to  Fowler's  position,  septic  fluids  have  a  tendency  to  accum- 
ulate. This  incision,  therefore,  represents  a  safety-valve  ; 
it  prevents  dangerous  tension,  which  would  promote  re- 
absorption  of  septic  products. 

In  seventeen  patients  suffering  from  wounds  by  projectiles, 
with  perforation  of  the  bowel,  Harris,  by  the  use  of  Murphy's 
incision,  had  seventeen  successful  cases. 

Murphy's  conception  and  technique  are  well  suited  to  the 
conditions  under  which  military  medical  service  is  carried 
out  in  the  ambulances  and  hospitals.  It  opens  up  for 
surgeons  a  path  they  should  resolutely  follow.  Here  is  no 
longer  the  complicated  operation  of  classical  laparotomy 
which  a  number  of  skilled  surgeons  could  not  repeat  at  the 
outside  more  than  three  or  four  times  in  a  day,  and  even  then 
by  neglecting  the  other  wounded  men  ;  a  fatiguing  operation, 
which  increases  shock,  and  is  liable  to  destroy  beneficial 
adhesions ;  an  operation  requiring  a  special  armamentarium, 
minute  aseptic  precautions,  and,  after  all,  that  ends  by  giving 
less  cases  of  cure  than  abstention  from  operation.  On  the 
other  hand.  Murphy's  incision  is  a  very  simple  and  rapid 
affair,  within  the  capacity  of  every  practitioner. 

At  Nancy,  Professor  Rohmer,  evidently  struck  by  the 
advice  given  in  our  communication,  carried  out  Murphy's 
incision  on  several  wounded  men  whom  we  saw.     Some 


i8o      WOUNDS  OF  THE  ABDOMEN 

were  on  the  road  to  recovery.  On  the  other  hand,  all  the 
patients  on  whom  Professor  Weiss  had  performed  laparotomy 
were  dead.  We  also  saw  at  Nancy  spontaneous  recovery 
from  wounds  of  the  abdomen  in  soldiers  who  had  remained 
for  several  days  lying  on  the  battlefield,  a  hail  of  projectiles 
passing  over  them,  and  forced  to  fast  all  the  time. 


CHAPTER  XVII 

WOUNDS  OF  THE  LUMBAR  REGION  AND 
OF  THE  KIDNEYS 

The  lumbar  region,  occupied  to  a  large  extent  by  the 
kidneys,  is  limited  on  the  inside  by  the  vertebral  column, 
below  by  the  iliac  crest,  above  by  the  twelfth  rib.  On  the 
outside  it  is  continuous  with  the  abdominal  wall  on  a 
level  with  the  flank. 

The  frequency  of  traumatisms  of  the  kidney  has  not  been 
precisely  determined.  They  are  included,  and  not  without 
reason,  amongst  wounds  of  the  abdomen. 

The  antero-posterior  course  is  the  most  frequent,  then  come 
the  postero -anterior  and  the  transverse  directions.  The  descend- 
ing colon  and  the  spleen  on  the  left  side,  the  ascending 
colon  and  the  liver  on  the  right,  and  the  pleura  on  each  side, 
are  often  simultaneously  injured. 

Contusions  are  rare,  and  without  much  interest ;  bleeding 
excoriations,  cul-de-sac  wounds,  through- and -through  perforating 
wounds,  are  the  lesions  generally  seen.  The  extent  of  the 
perforations  is  in  proportion  to  the  velocity  of  the  projectile. 
If  the  latter  is  slight  or  average,  the  track  is  narrow,  and 
not,  or  very  little,  fissured  ;  it  is  wide  and  fissured  with 
great  velocity  and  with  a  short  range.  The  perforations 
are  clear  or  prolonged  by  multiple  and  starred  fissures, 
especially  near  the  aperture  of  exit.     In  explosive  firing  the 

i8i 


i82       WOUNDS  OF  THE  LUMBAR  REGION 

kidney  may  burst ;  the  organ  is  fissured,  deeply  divided, 
separated  into  several  bleeding  fragments.  The  post-renal 
cellular  tissue,  less  divided  than  the  renal  tissue,  partly 
obliterates  the  posterior  wound. 

The  pelvis  of  the  kidney  and  the  ureter  are  divided,  per- 
forated, and  torn.  Their  lesions  give  rise  to  a  flow  of  urine, 
which  may  become  infiltrated  in  the  perirenal  tissue;  On 
the  other  hand,  wounds  of  the  parenchyma  by  bullets  do 
not  produce  any  outflow  of  urine. 

Wounds  of  the  renal  arteries  and  veins  are  followed  by 
serious  haemorrhage,  and  with  these  lesions  there  is  a  risk 
of  mortification  of  the  kidney. 

Outflow  of  itvine  from  the  posterior  wound,  a  pathognomonic 
sign,  is  exceptional  (parenchymatous  lesions,  narrowness  of 
the  wound,  mixture  of  urine  and  blood).  Inflltraticn  of  urine, 
which  may  form  a  lumbar  urinary  tumour,  with  a  tendency, 
to  diffusion  towards  the  iliac  fossa  behind  the  peritoneum, 
is  a  characteristic  of  wounds  of  the  pelvis  of  the  kidney  or 
of  the  ureter. 

HcBmaturia,  a  characteristic  symptom,  lasting  generally 
for  several  days,  is  a  very  valuable  sign,  but  it  has  been 
observed  in  only  one-thirty-fifth  of  the  peripheral  wounds. 
It  would  seem  only  to  occur  in  central  wounds. 

Oliguria  and  anuria  must  also  be  mentioned. 

The  relations  of  the  external  apertures  with  the  region  occupied 
by  the  kidney  furnish  very  valuable  indications  in  the  diag- 
nosis. In  width,  the  kidney  occupies  the  middle  third  of 
the  space  included  between  the  spinous  apophyses  and  the 
lateral  section  of  the  body,  and  in  height,  the  space  that 
extends  from  a  superior  horizontal  line  passing  across  the 
eleventh  rib,  to  an  inferior  one  which  would  just  touch  the 
second  or  third  lumbar  vertebra. 

The  immediate  treatment  presents  nothing  in  particular  : 
wide  dressings,  absolute  rest,  nothing  to  drink.  We  must 
not   meddle  with   renal   effusions   when  they  are  aseptic. 


WOUNDS  OF  THE  LUMBAR  REGION       183 

For  retention  of  urine,  repeated  catheterism,  or  a  catheter 
tied  in. 

For  profuse  haemorrhage,  general  haemostatics ;  in  case 
of  insufficiency,  liimhar  incision,  search  for  the  kidney,  direct 
compression  by  means  of  an  aseptic  pad,  fixed  by  a  partial 
suture  to  prevent  its  being  pressed  out,  its  action  being 
assisted  by  an  anterior  compression  of  abdomen  by  a  pad 
of  cotton- wool. 

We  should  not  meddle  with  a  fissured,  even  a  divided 
kidney  ;  the  fragments  which  are  nearly  free  are  alone  to 
be  removed. 

For  the  urinary  outflow  or  a  perinephritic  abscess,  lumbar 
incision.     For  pyonephrosis,  nephrotomy. 

The  gravity  of  these  wounds  is  especially  due  to  both 
the  kidney  and  the  colon  being  injured ;  isolated  wounds 
have  generally  a  rather  favourable  prognosis.  They  usually 
heal  in  two  or  three  weeks.  With  regard  to  complicated 
wounds,  their  mortality  was  formerly  50  per  cent,  (haemor- 
rhage, one-third  of  the  deaths ;  infection  complications,  two- 
thirds),  but  the  bad  prognosis  has  diminished  with  the 
present  bullets,  although  it  is  impossible  to  give  precise 
information  on  this  point. 


CHAPTER  XVIII 

WOUNDS  IN  THE  REGION  OF  THE 
PELVIS 

Bladder,  Rectum. 

Wounds  of  the  Soft  Parts. — Ordinary  characteristics 
and  treatment  are  the  same  as  those  we  see  and  employ  in 
bullet  lesions.  The  furrows  and  culs-de-sac  produced  by  shell 
splinters  are  often  large.  The  tracks  made  in  the  gluteal 
region  expose  the  patient  to  grave  haemorrhage  (gluteal  and 
ischiatic  vessels  and  their  branches) ;  temporary  plugging, 
ligature  after  relieving  constriction  by  free  incisions.  The 
plugging  should  not  he  left  in  sittt  for  long,  as  so  doing  would 
render  extremely  grave  putrid  suppuration  liable  to  occur, 
and,  as  we  have  lately  seen  in  a  German  wounded  man, 
haemorrhagic  suffusion  of  the  pelvis,  of  the  pelvic,  iliac,  and 
Retzian  regions,  with  possible  diffuse  aneurysms. 

LesioijS  of  the  Sciatic. — Nothing  special  in  the  treat- 
ment. 

Lesions  of  the  Pelvic  Bones. — They  are  the  same  as 
lesions  Qi  flat  or  spongy  bones:  Oval  or  oblique  perfora- 
tions, either  quite  clean  or  with  a  few  short  sjplinters  from 
the  internal  table,  sometimes  indentations  or  excoriatiojjs. 
Contusion  is  possible. 

Pelvis. — Penetration  of  the  pelvis  by  bullets  with  solution 
,OF  CONTINUITY  does  not  exist  (twenty  bullets  have  passed 
through   the   pelvis   without   causing   ffactujre — Pelorme). 

784 


BLADDER,  RECTUM  185 

Immobilization  of  the  pelvis,  therefore,  by  a  special  appar- 
atus is  an  inexplicable  procedure. 

Nothing  particular  with  regard  to  treatment. 

The  pelvic  organs  are  struck  in  their  intra-  or  extra- 
peritoneal portions,  or  simultaneously  in  both.  This  division 
should  be  remembered. 

The  track  is  generally  antero-posterior,  and  corresponds — 
(i)  to  the  hypogastrium,  to  the  floor  of  the  perinaeum,  to  the 
notches  ;  (2)  to  the  pelvis. 

A  transverse  or  oblique  course  is  more  uncommon. 

Wounds  of  the  Bladder. — Contusions,  excoriations,  cul- 
de-sac  wounds,  are  exceptional ;  total  perforations  habitual. 
Orifices  equal  or  inferior  to  the  size  of  the  bullet,  generally 
narrow.  The  perforation  of  the  serous  coat  is  small,  that  of 
the  muscular  coat  more  extensive,  and  that  of  the  mucous 
coat  intermediate  as  regards  dimensions.  Hernia  of  the 
mucous  membrane.    Bursting  is  rare  (explosive  projectiles). 

Tearing  and  puncture  are  possible  by  splinters. 

Diagnosis. — The  diagnosis  is  generally  not  difficult ;  it  is 
anticipated  by  the  relations  of  the  track  with  the  bladder,  and 
would  be  confirmed  by  the  escape  of  tirine  through  the  wound 
and  by  hematuria,  either  in  spontaneous  micturition  or  after 
the  use  of  the  catheter.  These  last  signs  in  conjunction 
with  the  first  are  pathognomonic,  but  they  are  often  absent. 

Let  us  call  attention  to  some  functional  signs  :  Radiating 
pain  in  the  hypogastrium,  in  the  perinseum,  the  loins,  the 
genital  organs ;  an  overwhelming  desire  to  pass  water,  to 
defaecate  ;  retention  of  urine  ;  finally,  when  there  are  com- 
plications, signs  of  peritonitis,  infiltration  of  urina,  urinary 
reabsorption. 

Prognosis. — Some  wounds  heal  easily,  .especially  narrow 
wounds  that  are  not  complicated  by  a  lesion  of  the  rectum. 
Too  often,  however,  we  see  peritonitis,  urinary  infiltration, 
the  formation  of  simple  or  urinary  abscesses,  which  develop 
iu  the  cavity  of  Retzius  and  in  tjje  ischio-fectal  foss.a^  and 


1 86    WOUNDS  IN  THE  REGION  OF  THE  PELVIS 

which  manifest  their  presence  by  a  hard,  oedematous,  some- 
times crepitant,  hypogastric  or  iliac  tumefaction,  and  by 
grave  general  symptoms  (perivesical  cellular  tissue),  or  by 
a  perineal  abscess. 

Immediate  death  is  rare ;  rapid  death  in  a  few  days  is 
frequent  (superacute  peritonitis) ;  delayed  death  takes  place 
from  the  eighth  to  the  twentieth  day.  It  follows  infiltration 
of  urine  or  pelvic  abscesses. 

These  wounds  are  rather  often  complicated  by  foreign 
bodies,  shreds  of  clothing,  pubic  hairs,  splinters,  bullets, 
which  may  be  the  starting-point  of  stone  in  the  bladder. 

What  is  the  proportion  between  deaths  and  recoveries  ? 
It  is  impossible  to  give  it  correctly.  Bartels  gives  a 
mortality  of  from  45  to  50  per  cent.  The  wounded  in  the 
Transvaal,  where  bullets  of  small  calibre  were  employed, 
rarely  recovered.  According  to  Makins,  the  extraperitoneal 
wounds  would  hardly  be  less  grave  than  the  intraperitoneal. 
A  concomitant  rectal  lesion  is  a  very  serious  complication. 

Treatment. — The  treatment  comprises  two  indications  : 
Prevent  the  effusion  of  urine  ;  contend  against  infection 
(peritonitis,  pelvic  or  perinaeal  infiltration). 

The  first  transport  of  the  patient  is  to  be  carried  out  very 
cautiously,  preferably  in  the  sitting  position ;  nothing  what- 
ever should  he  given  to  drink — this  is  capital;  decubitus 
facilitates  the  outflow  of  urine  ;  wide  dressing  often  renewed 
— these  are  the  first  indications  to  fulfil.  The  wounded  man 
should  expressly  he  treated  on  the  spot  where  he  fell. 

Catheterisni,  which  was  extolled  by  Larrey,  is  still  the 
easiest  and  safest  primary  therapeutic  measure ;  it  is  also 
the  one  most  capable  of  generalization.  We  all  know  its 
incidental  difficulties,  its  occasional  inadequacy. 

We  must  also  make  use  of  catheterisni  with  the  instrument 
tied  in  and  changed  every  third  day,  of  intermittent  catheterisni 
if  the  tied-in  catheter  is  not  tolerated.  Deep  drainage  of  the 
wound  is  advisable  when  the  lesion  is  large. 


BLADDER,  RECTUM  187 

The  button-hole  median  pevinceal  incision,  which  was  recom- 
mended formerly  when  the  catheter  was  badly  tolerated,  is 
replaced  nowadays  by  suprapubic  cystotomy  —  an  excellent 
operation,  but  not  capable  of  being  generaHzed. 

In  cases  of  peritonitis.  Murphy's  incision.  Experience 
will  show  up  to  what  point  it  may  be  employed  primarily. 

Free  laparotomy,  with  suture  of  the  bladder,  will  be 
exceptional. 

Wounds  of  the  Rectum.— Isolated  or  concomitant 
with  wounds  of  the  bladder,  lesions  of  the  rectum  present 
the  same  characteristics  as  wounds  of  the  remainder  of  the 
intestine  or  of  the  bladder.  They  are  either  sub-  or  intra- 
peritoneal. We  may  consider  it  a  case  of  the  latter  when 
the  lesion  lies  at  5  or  6  centimetres  from  the  anus ;  but 
generally  the  wound  is  both  intra-  and  extra-peritoneal. 

Escape  of  f cecal  matter  from  the  aperture  of  exit  is  the 
pathognomonic  sign  of  rectal  wounds,  but  it  is  often  absent 
on  account  of  their  narrowness.  Escape  of  flatus  and  of 
blood  through  the  anus  are  other  characteristic  signs,  but 
they  also  may  be  absent. 

We  must  abstain  from  injections  if,  when  given  through 
the  wound,  they  return  through  the  anus.  Rectoscopic 
examination  very  rarely  can  be  utilized.  Rectal  explora- 
tion with  the  finger  sometimes  enables  us  to  discover 
the  wound  (tactile  sensation  and  blood  at  the  end  of 
the  finger).  The  length  of  the  index  is  about  that  of  the 
extraperitoneal  portion  of  the  rectum. 

Simultaneous  lesions  of  the  bladder  and  rectum  may  be 
recognized  by  the  signs  of  a  wound  of  both  of  them. 

To  prevent  perirectal  infection  is  the  principal  indication  of 
the  treatment.  Dilatation  of  the  sphincter  is  a  practice  that 
is  often  employed,  owing  to  its  simplicity.  Intrarectal 
dressing  with  vaseline  and  iodoform  is  preferable  to  the 
introduction  of  gauze.  In  the  event  of  the  latter  being 
used,  a  large  drainage-tube  should  be  placed  in  the  centre 


1 88    WOUNDS  IN  THE  REGION  OF  THE  PELVIS 

of  the  dressing.  Enemata  are  dangerous.  Once  a  faecal 
abscess  has  formed,  or  is  threatening,  posterior  rectotomy. 

Perirectal  and  presacral  abscesses  should  be  opened  by  a 
perinaeal  incision,  followed  or  not  by  precoccygeal  separa- 
tion ;  iliac  abscesses  by  the  incision  used  for  tying  the  ex- 
ternal iliac ;  abscesses  of  the  space  of  Retzius  by  a  supra- 
pubic incision. 

No  food  at  first,  then  alimentation  consisting  only  of 
meat ;  opium  must  be  given.  These  are  the  principal 
measures  that  help  the  treatment. 

Wounds  of  the  Prostate  and  of  the  Urethra. 

In  a  perinaeal  or  abdomino-perinseal  track  the  prostate 
and  the  deep  part  of  the  urethra  may  be  injured.  The 
treatment  of  the  former  is  included  in  that  of  the  other 
wounded  parts. 

These  wounds  are  recognized  by  the  urethrorrhagia  and 
by  the  escape  of  urine  through  the  woimd^  sometimes,  how- 
ever, by  direct  examination. 

Delicate  catheterism,  though  dangerous,  is  a  last  resource. 
De  visu  we  must  judge  of  the  feasibility  of  suturing  the 
urethra.  Puncture  of  the  bladder  may  be  necessary.  With 
regard  to  retention  of  urine  and  urinary  abscess,  which  may 
complicate  the  urethral  lesion,  they  necessitate  a  button- 
hole perinaeal  incision. 

Wounds  of  the  Genital  Organs. 

Woumls  of  the  genital  organs  are  often  concomitant  with 
lesions  of  the  thighs  or  of  the  pelvis. 

They  are  not  rare.  We  have  seen  a  complete  series  of 
these  cases  in  the  hospitals  of  Nancy,  and  more  particularly 
in  those  of  Bordeaux. 

Perforations  of  the  scrotum  give  rise  to  a  hcematic  swelling, 
sometimes   of   a   considerable    size;    the   clots  it  contains 


WOUNDS  OF  THE  CENlTAL  ORGANS      i8g 

must  .be  cleared  away.  Extensive  tearing  with  escape  of 
the  testicle  would  necessitate  immediate  reduction  with  a  few 
fixation  sutures  (Delorme). 

The  testicle,  owing  to  its  mobility  and  elasticity,  often 
escapes  the  bullets  that  go  through  the  scrotum.  On  other 
occasions  it  is  excoriated  or  perforated.  The  treatment  is 
to  reunite  the  edges  of  the  wound  after  reduction  of  the 
herniated  testicular  tissue. 

The  penis  may  be  notched  or  perforated  in  its  cavernous 
or  urethral  portions.  With  the  old  bullets  division  of  the 
urethra  was  scarcely  ever  noticed.     Catheter  to  be  tied  in. 

The  haemorrhage  that  follows  wounding  of  the  cavernous 
bodies  is  not  so  grave  as  one  might  suppose.  The  consecu- 
tive curvature  of  the  penis,  which  is  quite  possible,  can  be 
treated  by  later  intervention. 


CHAPTER  XIX 

WOUNDS  OF  THE  VERTEBRAL  COLUMN 
AND  OF  THE  SPINAL  CORD 

These  wounds  are  comparatively  rare.  During  the  War 
of  Secession  only  643  cases  were  seen,  and  in  the  war  of 
1870  only  289.  Yet  we  have  just  come  across  a  relatively 
large  proportion  of  them  in  the  ambulances  and  hospitals 
at  Nancy. 

The  tracks  of  the  bullets  that  strike  the  vertebral  column 
or  the  spinal  cord  are  antevo-postenor,  postero-anterior,  trans- 
verse, or  oblique. 

The  first  affect  simultaneously  the  important  organs  of 
the  face,  the  neck,  the  chest,  the  abdomen,  the  pelvis.  They 
are  exceptional. 

The  second,  less  rare,  endanger  the  posterior  arches  of 
the  vertebrae. 

When  the  axis  of  the  track  is  median,  we  find  in  it 
notches  and  perforations  of  the  bodies  of  the  vertebrae  or  of 
the  apophyses. 

Lesions  of  the  Bones. — Bullets  notch  the  lamina,  which 
are  really  flat  bones,  splinter,  fissure,  perforate  them,  the 
splinters  being  either  sedentary  or  thrown  forward,  and 
finally  separate  them. 

The  laminae,  either  over  or  under  those  that  have  been 
directly  hit,  are  sometimes  obliquely  or  vertically  fractured 
by  the  neighbouring  laminae. 

190 


MENINGO-MEDULLARY  LESIONS  191 

The  spinous  processes  present  the  same  lesions. 

If  these  last  are  carried  against  the  vertebral  bodies, 
their  laminge,  or  their  apophyses,  the  strength  of  the  vertebral 
column  is  not  impevilled.     This  fact  should  be  remembered. 

Big  shell  fragments  give  rise  to  contusions,  fractures, 
crushing  and  bony  abrasions. 

Bullets  or  splinters  may  penetrate  the  vertebral  canal. 

Meningo- Medullary  Lesions.— The  meninges  are  gene- 
rally perforated  in  a  linear  direction ;  sometimes  they  are 
torn.  The  spinal  cord  presents  very  diverse  lesions,  going 
from  shock  and  compression  to  contusion  and  wounding. 

Shock  is  characterized  by  small  apoplectic  foci.  The  dis- 
tance action  of  armour-piercing  shells  lends  to  this  shock 
a  frequency  and  an  importance  unknown  to  our  prede- 
cessors. 

Compression  is  the  result  of  an  effusion  of  blood  either 
inside  or  outside  the  dura  mater.  These  compressive 
hismatomata  are  exceptional  in  war  surgery  (Otis).  Compres- 
sion is  also  caused,  but  less  rarely  than  by  hsematorrhachis, 
by  the  dislocation  of  a  vertebral  arch,  by  splinters,  by  a 
projectile,  an  abscess,  a  piece  of  callus  (Laurent). 

Haematic  compression,  after  having  revealed  its  presence 
by  aggravation  of  the  symptoms  from  the  first  hours  or  the 
first  days,  diminishes  rapidly  and  spontaneously ;  this  shows 
the  uselessness  of  intervention.  Compression  due  to 
foreign  bodies  ends  in  softening  and  sclerosis ;  this  shows 
the  utility  of  intervention. 

Contusions  have  degrees  of  severity  from  slight  suffusion 
of  blood  with  superficial  dissociation  of  medullary  elements, 
to  attrition,  which  is  localized  in  situ,  to  the  opposite  points 
and  to  partial  destruction. 

Wovmds  are  small  punctures,  grazes,  furrows,  grooves  more  or 
less  deep,  perforations,  incomplete  sections,  very  rarely  com- 
plete, the  result  of  projectiles  or  of  splinters.  Besides,  big 
projectiles  may  give  rise  to  elongations. 


192    Wounds  of"  the  vertebral  column 

Oil  the  level  of  the  cauda  equina  lesions  are  very  limited. 

The  spinal  roots  are  bruised,  divided,  or  reduced  to  pulp. 

Diagnosis  of  MeduUo-Rhachidian  Lesions. — The 
vertebral  column  undergoes  no  deformation,  but  movement 
is  very  painful,  almost  impossible.  The  patient  holds  him- 
gelf  stiffly. 

Sometimes  very  slight  pressure  allows  us  to  perceive  an 
abnormal  mobility  and  a  localized  crepitation. 

Escape  of  cerebrospinal  fluid  is  exceptional. 

The  functional  signs  vary  according  to  the  seat  of  the 
lesion. 

Lesions  of  the  liimhar  spinal  cord,  which  commences  at 
the  first  lumbar  vertebra,  may  be  disclosed  by  paralysis  of 
the  lower  limbs,  retention  or  incontinence  of  urine  and 
of  faeces. 

Those  of  the  dorsal  spinal  cord  by  paraplegia,  paralysis  of 
the  abdominal,  dorsal,  and  intercostal  muscles,  as  far  as  the 
limits  of  the  lesion,  by  recto-vesical  paralysis,  elevation  of 
temperature,  gastric  crises,  and  vomiting. 

Those  of  the  cervical  region  by  the  preceding  signs,  to 
which  must  be  added  Cheyne-Stokes  respiration,  hiccough, 
dysphagia,  contraction  of  the  pupils,  elevation  of  the  tem- 
perature, rapid  sacral  decubitus. 

We  will  now  return  to  the  signs  that  allow  us  to  recognize 
generalized  meningeal  shock. 

The  meningo -medullary  irritation  produced  by  splinters 
gives  rise  to  atrocious  pain,  epileptiform  convulsions  (Otis), 
contractions  of  a  tetanic  form.    This  fact  should  be  remembered. 

Destruction  is  known  to  have  happened  by  signs  of  deficit. 

If  we  refer  to  facts  cited  by  Otis,  we  find  that  bullets 
which  compress  and  depress  the  medullary  coverings  or 
become  fixed  in  the  medulla  cause  less  acute  irritating 
phenomena  than  splinters. 

Extensive  haemorrhage  outside  the  dura  mater,  in  cases 
of  common  fracture,  causes  similar  pain,  though  it  is  less 


MEDULLO-RHACHIDIAN  LESIONS  193, 

intense,  and  appears  a  little  less  rapidly  and  not  imme- 
diately ;  but  this  haemorrhage  is  exceptional  in  the  open 
lesions  produced  by  bullets,  so  that  differential  diagnosis  is 
not  difficult  in  such  cases. 

Prognosis. — Spinal  traumatisms  that  have  shown  resis- 
tance to  the  first  symptoms  often  end  happily.  The  same 
cannot  be  said  of  rather  deep  medullary  lesions.  They 
carry  a  very  unfavourable  prognosis.  They  are  nearly 
alw^ays  fatal. 

The  deplorable  results  following  surgical  intervention  in 
the  Balkan  War  command  abstention  in  medullary  lesions. 
The  focus  of  a  lesion  of  the  medulla  is  often  absolutely 
impossible  to  find  or  to  limit ;  haemorrhagic  effusion  and 
foci  cannot  be  differentiated  from  damage  to  the  medullary 
elements  themselves;  injury,  nearly  always  limited,  cannot 
indicate  a  suture ;  finally,  a  wound  of  the  medulla  by  pro- 
jectiles is,  so  to  speak,  invariably  fatal  (Laurent). 

Dent's  mortality  rate  of  50  to  60  per  cent,  in  the  Trans- 
vaal has  reference  simultaneously  to  lesions  of  the  vertebral 
column  and  of  the  spinal  cord. 

Treatment. — Laminectomy,  that  seemed  more  justifiable 
than  more  extensive,  more  radical  intervention,  has  not 
given  more  brilliant  results  to  those  who  have  attempted  it 
than  other  surgical  measures.  Nevertheless  it  is  indicated, 
if  not  as  a  regular  operation,  at  least  as  an  atypical  opera- 
tion, in  certain  cases  in  which  there  seem  no  other  means  of 
replacing  it  with  advantage.  For  instance,  when  sharp 
splinters  forced  against  the  meninges  cause  atrocious  pain ; 
when  it  is  practised  in  endeavours  to  remove  an  irritating 
projectile  whose  location  has  been  duly  discovered  ;  finally, 
when  it  is  to  facilitate  the  emptying  of  an  intrarhachidian 
abscess. 

Excepting  in  these  cases,  the  treatment  must  be  expectant ; 
this,  however,  does  not  mean  that  it  should  be  inactive. 

From  the  field  of  battle  to  the  first-aid  station  or  to  the 

13 


194     WOUNDS  OF  THE  VERTEBRAL  COLUMN 

ambulance  the  wounded  man,  after  having  been  gently 
raised,  should  be  transported  with  the  greatest  care  and  the 
most  extreme  precaution,  especially  without  being  jerked. 

A  soldier  hit  in  the  back  and  unable  to  move  his  lower 
limbs  is  to  be  looked  upon  by  the  stretcher-bearers  as 
having  experienced  a  fracture  of  the  vertebral  column. 

His  greatcoat  must  be  utilized  as  a  hammock  both  in 
lifting  him  up  and  in  setting  him  down. 

He  must  not  be  transported  any  distance. 

The  application  of  Bonnet's  hollowed  out  splint  can  be  of 
no  use,  as  there  is  no  solution  of  continuity. 

The  usual  aseptic  dressing  must  be  broad.  Injections  of 
morphine  if  necessary.     Aseptic  catheterism. 

In  cases  of  threatened  sloughing  or  of  sharp  pain  coming 
on  at  the  slightest  displacement,  lay  the  patient  on  a 
stretcher,  the  canvas  of  which  has  been  extensively  cut 
away  in  a  circular  form  on  a  level  with  the  soldier's  loins 
and  gluteal  region.  The  edges  of  this  opening  must  be  well 
padded  with  cotton-wool.  The  dressings  will  be  kept  in 
place  by  a  large  compress  going  round  the  patient's  back 
like  a  hammock,  and  fixed  to  the  canvas  of  the  stretcher  by 
safety-pins.  By  this  means  the  dressing  can  be  easily 
renewed  without  moving  the  wounded  man. 

As  a  general  rule  we  must  refrain  from  going  primarily  in 
search  of  loose  or  tolerated  splinters^  as  they  are  insignificant, 
and  may  be  useful  in  the  process  of  repair. 

When  there  is  abundant  effusion  of  cerebrospinal  fluid,  we 
must  put  compression  on  the  wound,  and  suture  it  if 
necessary. 

The  meningeal  infection  should  be  treated  by  lumbar 
puncture,  in  case  of  need  by  drainage,  which  must  not  reach 
the  spinal  cord. 

In  spite  of  ail  this  necessary  treatment,  the  evolution  will 
nearly  always  be  distressing  ;  after  a  few  weeks  of  suffering 
these  patients  succumb,  if  the  lesion  is  high  up. 


CEREBRO'MEDULLARY  SHOCK  195 

Cerebro-Medullary  Shock. — Here  we  have,  as  it  were, 
a  fresh  chapter,  which  the  use  of  explosive  projectiles  has 
lately  opened  wide,  and  of  which  the  elucidation  was  com- 
menced by  the  surgeons  in  the  Balkan  War,  particularly  by 
Professor  Laurent  of  Brussels."^'  We  are  desirous  of  draw- 
ing the  attention  of  all  surgeons  in  the  present  war  to  his 
work. 

We  have  already  seen  several  cases  of  this  shock  in  the 
base  hospitals. 

This  shock  may  be  slight  and  only  manifested  by  torpor 
and  tingling,  specially  in  the  lower  limbs,  by  difficulty  in 
walking,  by  hyperaesthesia  with  or  without  giddiness,  by 
loss  of  consciousness. 

It  leaves  behind,  for  a  more  or  less  lengthy  period,  a 
certain  slowness  of  ideas,  a  kind  of  indifference,  and  reten- 
tion of  urine. 

"  When  of  a  graver  kind,  it  causes  arrest  of  functions ; 
the  wounded  man  falls  into  torpor,  becomes  inert  as  if 
absolutely  crushed,  and  all  four  limbs  and  the  sphincters 
are  paralyzed  "  (Laurent). 

Recovery  is  rapid  in  many  cases,  and  occurs  in  a  few 
days ;  but  paralysis  and  mental  troubles  may  persist  for 
some  time. 

These  phenomena  were  observed  in  soldiers  who  were  2  to 
10  or  15  metres  distant  from  the  point  where  an  explosive 
percussion  shell  fell  and  burst,  in  that  angular  zone  in 
which  the  shell  fragments  follow  an  ascending  trajectory. 
In  typical  cases  the  men  have  not  been  struck  by  fragments 
of  the  shell,  but  they  have  sustained  on  the  vertebral 
column,  the  spinal  cord,  and  the  brain,  the  effects  of  the 
excessive  concussion — the  shock  of  the  column  of  air  which 
has  been  intensely  and  violently  displaced.  The  wind  of 
the  shell  on  other  occasions,  the  contusion  brought  about 

*  The  War  in  Bulgaria  and  in  Turkey :  A  Campaign  of  Eleven  Months, 
by  Professor  O.  Laurent.     Maloine,  1914. 


196     WOUNDS  OF  THE  VERTEBRAL  COLUMN 

by  torn-up  clods  of  earth,  are  the  ordinary  causes  of  these 
effects ;  but  they  may  also  be  produced  by  the  direct  shock 
of  a  shell  fragment  or  of  a  bullet  hitting  the  vertebral 
column.  Laurent  reports  a  case  in  which  the  shock  was 
the  result  of  the  grazing  of  the  spine  by  an  intact  shrapnel, 
another  in  which  it  was  produced  by  the  shrapnel  cylinder, 
and  another  in  which  the  wounded  man  remained  buried 
under  masses  of  earth  and  of  stones  that  had  been  upheaved 
by  the  shell.  The  cases  in  this  last  category  are  very 
different,  in  regard  to  their  mechanism,  from  the  first  we 
have  mentioned,  which  are  altogether  typical,  and  in  which 
the  shock  seems  to  have  been  the  result  of  a  disturbance 
produced  by  the  gases  and  the  wind  of  the  big  projectile. 

In  the  case  of  certain  wounded  men  who,  knocked  over 
by  the  gas  and  wind  of  the  shell,  remain  on  the  spot 
where  they  fall,  it  might  be  difficult  to  distinguish  the 
psychical  from  the  physical  mischief.  The  symptoms  that 
may  be  verified  can  only  be  attributed  to  the  latter,  in 
cases  where  these  patients — and  we  have  seen  a  few — have 
been  helped  up  and  taken  some  distance  without  again 
falling  on  their  back. 


CHAPTER  XX 

WOUNDS  OF  THE  UPPER  LIMBS 

The  new  tactics  in  warfare,  which  embody  prolonged 
firing  from  improvised  trenches,  render  the  different  seg- 
ments of  the  upper  limbs  particularly  vulnerable,  the  result 
being  that  wounds  of  these  parts  are  seen  at  present  with  a 
frequency  formerly  absolutely  unknown.  The  respective 
positions  of  the  forearm  and  of  the  left  arm  during  firing 
make  these  two  segments  especially  liable  to  simultaneous 
wounds.  The  hands  also  are  very  frequently  hit ;  and  at 
the  time  of  bursting  of  shrapnel  the  fingers  are  often 
wounded  because  they  are  unprotected  on  the  knapsack, 
that  they  hold  up  to  protect  the  head  (French  soldiers). 

Wounds  of  the  Hand  and  Fingers. 

The  hand  is  the  most  exposed  part  of  the  upper  limb. 
Its  lesions  are  more  than  lo  per  cent,  of  the  wounds  of  the 
limb  (Ferraton).  They  are  rarely  isolated.  Concomitant 
lesions  frequently  take  effect  on  the  head,  the  face,  or  the 
chest. 

Wounds  of  the  hands  and  fingers  are  antero -posterior,  more 
often  postero -anterior,  sometimes  transverse,  exceptionally 
axial  or  longitudinal. 

Wounds  of  the  Soft  Parts. — The  fleshy  parts  of  the 
thenar,  of  the  hypothenar,  of  the  metacarpal  spaces,  even  of 
the  fingers^  are  furrowed,  sometimes  perforated  by  bullets. 

197 


198  WOUNDS  OF  THE  UPPER  LIMBS 

Osseous  Lesions. — The  phalanges,  even  the  second  and 
third,  may  be  indented  or  perforated.  In  spite  of  their 
small  size,  they  present  the  typical  lesions  of  fractures  of 
the  long  bones.  On  a  level  with  the  articulations,  radio- 
graphy shows  the  epiphysial  lesions,  perforations  with 
or  without  separation  of  small  lateral  wedges  of  bone. 

On  the  metacarpals,  which  really  are  long  bones  with 
compact  tissue,  we  see,  on  the  diaphysis,  oblique  or  trans- 
verse contact  fractures,  also  grooves  and  perforations,  with 
typical  radiating  fissures.  Perforation  of  the  diaphysis, 
with  its  two  principal  lateral  splinters  and  a  few  subdivided 
splinters  either  free  or  adherent,  are  the  most  common 
lesions.  The  splinters  are  short,  rarely  displaced.  The 
grooves  or  the  perforations  of  the  epiphyses  are  typical, 
and  the  radiating  fissures  cuneiform. 

In  the  lesions  from  postero -anterior  firing,  the  free  splinters 
are  forced  towards  the  palm  of  the  hand.  They  are  very 
difficult  to  get  at.  When  the  firing  is  antero-posterior,  they 
are  superficial ;  and  when  they  have  been  forced  onwards, 
they  will  be  found  to  have  notoMy  increased  the  extent  of 
the  cutaneous  perforation.  When  the,  range  is  short,  the 
soft  parts  of  the  dorsum  of  the  hand  almost  present  the 
characteristics  of  explosive  fire. 

If  hit  transversely,  the  hand  and  the  fingers  nearly 
always  show  multiple  fractures,  which  belong  to  the  same 
type,  with,  however,  the  peculiarity  that  the  lesion  often 
increases  in  size  from  the  first  to  the  last  fingers,  from  the 
first  to  the  last  metacarpal  bones  through  which  the  bullet 
has  passed. 

Complications. — Hemorrhage  is  the  most  important  and 
frequent  primary  complication  of  these  wounds.  It  is 
specially  profuse  when  the  projectile  has  penetrated  the 
palm  above  the  horizontal  line,  starting  from  the  ulnar 
border  of  the  hand,  and  going  to  the  inferior  border  of  the 
thumb  in  forced  abduction  (line  of  E.   Boeckel).     In  this 


WOUNDS  OF  THE  HAND  AND  FINGERS      199 

case  one  of  the  palmar  arches,  sometimes  both  of  them, 
might  be  wounded.  A  diagnosis  may  be  made  of  a  lesion 
of  the  deep  arch,  if  the  wound  corresponds  to  the  bases 
of  the  thenar  and  hypothenar  eminences. 

Metallic  foreign  bodies  and  displaced  splinters  constitute 
the  second  immediate  complication.  A  bullet  may  stop  in 
a  phalanx.  The  hand  being  bare,  there  are  no  foreign  bodies 
derived  from  the  clothes. 

Opening  of  the  sheath  of  the  flexor  proprius  poUicis,  and 
also  of  the  common  sheath,  which  is  prolonged  to  the 
extremity  of  the  little  finger,  renders  these  sheaths  liable 
either  to  the  simple  infection  of  reaction  or  to  suppuration, 
as  well  as  to  the  opening  up  of  the  sheaths  of  the  finger 
muscles.  Between  Boeckel's  line  and  the  lower  palmar 
fold  of  flexion  there  is  a  region  in  which  no  sheath  is 
reached. 

Treatment. — After  an  application  of  iodine,  a  simple 
dressing  is  sufficient.  The  palmar  splint,  to  secure  immo- 
bility, only  seems  to  be  of  use  when  the  bones  of  the 
metacarpus  are  very  much  displaced.  However,  it  is  a 
good  plan  to  often  keep  up  extension  of  the  fingers  on 
account  of  their  tendency  to  flex  and  to  remain  flexed. 

After  temporary  compression,  Boeckel's  incision  and  the 
median  palmar  incision  of  Delorme  will  allow  the  surgeon 
to  ligature  the  two  ends  of  the  indented  or  divided  palmar 
arches.  Let  us  remind  medical  men  that  our  incision 
extends  from  the  centre  of  the  heel  of  the  hand  to  above 
the  commissure  of  the  index  and  middle  fingers.  By  the 
dorsal  route  one  may,  perhaps,  after  removal  of  the  splinters 
and  of  the  heads  of  the  metacarpal  bones,  reach  the  deep 
palmar  arch. 

Our  median  palmar  incision  is  the  best  for  removal  of 
foreign  bodies  from  the  palm,  as  also  for  opening  deep 
abscesses.  Opening  abscesses  of  the  sheaths  is  carried 
out  either  by  a  thenal  incision  that  opens  the  sheath  of  the 


200  WOUNDS  OF  THE  UPPER  LIMBS 

flexor  proprius,  or  by  a  hypothenal  incision  (internal  palmar 
incision) ;  finally,  if  necessary,  by  radio-ulnar  incisions. 

Phlegmonous  reactions  of  the  sheaths  seem  to  us  much 
less  grave  than  formerly,  and  unlikely  to  necessitate  the 
extensive  freeing  of  the  radio-carpal  ligament  that  has 
been  proposed. 

Baths  of  tepid  boiled  water  are  always  useful  in  phleg- 
monous inflammation.  Hydrogen  peroxide  also  renders 
signal  service  in  these  cases. 

Conservatism  is  indispensable  in  wounds  of  the  hand,  and,  at 
first,  should  he  pushed  to  its  extreme  limits.  But  care  must  be 
taken  to  employ  passive  motion  to  both  the  wounded  and  the 
sound  fingers  as  soon  as  possible,  to  avoid  the  stiflhess 
which  is  so  frequent,  so  regrettable,  and  so  often  ascribed  to 
surgical  inaction. 

However,  if,  at  the  beginning,  conservatism  should  be, 
so  to  speak,  excessive,  because  the  smallest  particles  of  the 
hand,  even  if  much  lacerated,  can  be  of  the  greatest  utility, 
yet  subsequently  there  must  be  no  hesitation  in  ridding  the 
patient  of  any  one  of  the  middle  fingers  that  happens  to  be 
irretrievably  ankylosed,  both  in  flexion  or  in  extension,  so 
that  it  is  not  only  useless,  but  also  troublesome  and  in  the 
way.  Too  extensive  and  too  weak  terminal  cicatrices,  as 
well  as  painful  cicatrices,  may  also  render  amputation 
necessary. 

Total  removal  of  the  splinters,  trimming  the  metacarpal 
fracture  by  means  of  resection,  are  condemned.  It  may  give 
rise  to  pseudarthrosis. 

Ferraton  has  very  justly  said,  in  speaking  of  the  treat- 
ment of  the  most  serious  traumatisms  (bursting  of  shells), 
"  the  most  extensive  mutilation  of  the  hand  and  fingers  never 
can  bring  about  such  functional  troubles  as  those  that 
would  be  caused  by  total  loss." 

Self- Mutilation. — In  all  wars,  even  during  the  present 
one,  the  question  has  been  raised  of  self-mutilation  carried 


WOUNDS  OF  THE  HAND  AND  FINGERS    201 

out  on  the  hand  and  fingers.  A  faint-hearted  soldier 
obtains  at  the  price  of  self-mutilation  the  safety  of  a  life 
which  probably  was  not  even  threatened. 

In  such  a  case  the  skilful  surgeon  jmist  act  up  to  his  strict 
duty.  He  owes  the  truth — all  the  truth — to  the  commanding 
officer ;  but  in  order  that  he  may  pronounce  his  verdict, 
on  his  soul  and  conscience,  the  truth  must  show  itself  very 
clearly ;  and  when  he  feels  the  slightest  doubt,  he  must 
refrain  from  coming  to  a  conclusion  of  mutilation. 

The  frequency  of  wounds  of  the  fingers  and  of  the  hand 
must  not  be  used  as  an  argument.  This  frequency  is  normal 
in  battle  during  the  present  wars,  as  the  bare  hand  is  very 
much  exposed  to  bullets. 

Diagnosis  is  based — On  the  verification  of  a  palmo- 
dorsal  wound,  especially  at  the  extremity  of  the  index  and 
middle  fingers  ;  but  mutilation  may  take  place  in  the  palm, 
as  we  have  already  seen.  The  wound  in  such  a  case  would 
still  be  palmo-dorsal.  This  sign  may  lead  us  to  a  presump- 
tion. In  battle,  wounds  of  the  fingers  and  hand  are  gener- 
ally dor  so-palmar. 

Formerly  a  sign  that  led  to  presumption  was  again  drawn 
from  the  state  of  the  wounds,  which  were  reduced  to  pulp, 
irregular,  split  up ;  whilst  wounds  received  from  a  distance 
are  regular.  On  the  other  hand,  it  must  be  confessed  that 
wounds  inflicted  for  self- mutilation  can  be  regular,  and 
accidental  lesions  reduced  to  pulp  and  lacerated. 

The  real  indication  is  furnished  by  the  burnt  appearance 
of  the  aperture  of  entry.  Around  the  wound,  even  in  all 
the  palm,  if  this  last  has  been  traversed,  the  epidermis 
is  dry  and  black,  the  edges  of  the  discoloration  being 
INCRUSTED  WITH  GRAINS  OF  POWDER.  Eveu  wheu  this  has 
disappeared,  grains  will  be  found  in  the  derma. 

Chemical  analysis  of  the  grains  in  the  epidermis  would 
perhaps  remove  our  last  doubts.  We  are  studying  this 
point. 


202  WOUNDS  OF  THE  UPPER  LIMBS 

The  presence  of  other  wounds  is  in  favour  of  the  man's 
innocence. 

Considering  the  gravity  of  the  disciplinary  decisions  that 
proceed  from  the  surgical  verdict,  it  is  indispensable  that — 

1.  In  conformity  with  tradition,  the  verdict  should  be  given 
by  a  mixed  Commission,  composed  of  surgeons  of  high  rank 
who  are  perfectly  acquainted  with  the  characteristics  of 
war  traumatisms,  of  a  few  staff  officers,  and  of  the  Provost- 
Marshal  and  his  officers. 

2.  The  verdict  should  be  given  on  a  pretty  near  date  to 
that  of  the  reception  of  the  wound ;  then  all  signs  are  very 
distinct. 

Wounds  of  the  Wrist. 

Wounds  of  the  wrist  are  not  very  frequent.  They  are 
7  to  8  per  cent,  in  the  total  of  wounds  of  the  limbs. 

An  inferior,  horizontal  line  passing  approximately  through 
the  superior  and  external  prominence  of  the  metacarpal 
bone  of  the  thumb,  and  a  superior  line  cutting  through:  the 
forearm  at  two  fingers'  breadths  above  the  styloid  process 
of  the  radius,  give  the  limits  of  the  wrist. 

Wounds  of  this  part  are  antero -posterior — these  are  rare  ;  or 
postero-anterior,  which  are  more  frequent,  especially  on  the 
left  side ;  finally,  axial,  especially  on  the  right.  We  can 
easily  understand  this  if  we  think  of  the  position  of  the 
soldier  when  firing. 

Wounds  of  the  Soft  Parts. — The  soft  parts  may  alone 
be  hit.  We  have  to  consider — Tendinous  lesions,  with  pene- 
tration of  the  sheaths  ;  wounds  of  the  vessels  and  of  the 
nerves. 

Osseous  Lesions. — When  the  bones  are  hit,  the  lesions 
differ  according  to  whether  the  projectile  has  taken  effect 
on  the  carpus  or  on  the  inferior  radio- ulnar  extremities. 

On  the  carpus  we  see  indentations  on  the  edges,  extensive 
furrows   on   the   surface,  perforations,  generally    simple,   all 


WOUNDS  OF  THE  WRIST  203 

revealed  by  localized  pain,  difficulty  of  movement ;  radio- 
graphic pictures  are  rarely  conclusive,  especially  with 
regard  to  the  relationship  of  the  track  to  the  affected  hones. 
Speaking  anatomically,  these  lesions  are  simple. 

Extension  or  limitation  of  the  damage  on  the  inferior 
radio-ulnar  extremities  are  governed  by  the  seat  of  the 
lesions.  The  line  of  the  epiphysis  and  diaphysis  rises  only 
a  centimetre  above  the  point  of  the  styloid  process  of  the 
radius. 

Below  this  line  the  furrows,  grooves,  and  perforations  are 
of  the  epiphysial  type — that  is  to  say,  circumscribed ;  above 
they  are  epiphysial-diaphysial — that  is  to  say,  often  radiated 
by  fissured  tracks  which  limit  more  or  less  completely 
wedges  that  have  an  articular  basis,  or  large  splinters. 

From  a  practical  point  of  view,  and  in  an  aseptic  wound, 
these  fissures  do  not  constitute  a  complication. 

Diagnosis. — In  such  a  superficial  articulation  the  diag- 
nosis of  bony  lesions  is  easy.  Localized  pain  make  us 
suspect  fissures,  radiography  sometimes  shows  them. 
Equally  easy  is  the  diagnosis  of  arterial  (ulnar,  radial)  and 
nervous  lesions  (median,  ulnar,  radial). 

Treatment. — Haemorrhage  is  easily  arrested  by  com- 
pression ;  afterwards  by  direct  ligature,  which  is  indispens- 
able in  these  cases  as  a  safeguard  against  a  relapse  of  the 
bleeding,  facilitated  by  the  extensive  palmar  and  dorsal 
anastomoses. 

Possible  infection  of  the  sheaths  would  necessitate  dorsal 
incisions,  lateral  incisions  on  the  line  of  the  ulnar  and 
radial  arteries,  or  median  palmar  incisions.  Being  an  un- 
covered region,  the  wrist  is  but  little  complicated  by  the 
presence  of  infecting  foreign  bodies. 

Conservatism  is  the  rule,  even  in  the  most  serious  traumatisms 
produced  by  explosive  fire.  Immobility  is  obtained  by  a  palmar 
splint.  Removal  of  splinters  from  the  carpus,  even  in 
infected    cases,    is   rarely   of   any   use,    by   reason   of   the 


204  WOUNDS  OF  THE  UPPER  LIMBS 

limitation  of  the  damage.     Clearing  out  the  wound  would 
only  be  necessitated  by  persistent  osteitis. 

Lesions  of  the  wrist  are  rarely  grave.  Passive  move- 
ments of  the  articulation  and  of  the  fingers  should  be  begun 
early. 

Wounds  of  the  Forearm. 

The  forearm  extends  from  the  superior  limit  of  the  wrist 
to  a  transverse  line,  passing  two  fingers'  breadths  below 
the  fold  caused  by  the  flexion  of  the  elbow. 

The  proportion  of  these  wounds  is  not  as  yet  completely 
established.  It  is  said  that  they  represent  a  tenth  of  the 
total  lesions  of  the  limbs. 

The  tracks  may  be  classed  as  antero-postefiov,  postero- 
anterior  (these  are  the  most  often  seen),  transverse,  which  are 
pretty  frequent,  and  also  the  most  serious  (fracture  of  both 
bones),  and  finally  axial. 

Wounds  of  the  Soft  Parts.— Nothing  particular  can 
be  said  on  this  subject. 

Osseous  Lesions. — With  regard  to  osseous  lesions,  they 
belong  to  the  diaphysial  type.  They  are  contusions,  cracks , 
fissures,  sometimes  revealed  by  radiography,  sometimes  by 
the  presence  of  localized  pain  (back  of  ulna)  ;  contact  fractures^ 
often  transverse  and  oblique,  or  with  large  splinters  ;  grooves, 
with  their  well-known  lines  of  fissures  ;  fractures  by  perforation, 
the  most  usual. 

The  adherent  splinters  are  relatively  short.  The  total 
length  of  the  osseous  focus  is  4,  6,  8,  10  centimetres.  The 
free  splinters  are  i  to  2  centimetres  longer.  Not  only  in 
fractures  of  but  one  bone,  but  even  in  fractures  of  both 
bones,  there  is  not  always  a  tendency  to  an  axial  or  a 
lateral  deviation.  But  it  is  a  mistake,  and  we  have  seen 
others  make  it,  to  treat  these  fractures  by  the  application 
of  a  simple  dressing,  however  thick  and  permanent  it  may 
JDe.     Such  a  proceeding  exposes  the  wounded  man  to  use- 


WOUNDS  OF  THE  FOREARM  205 

less  pain,  to  consecutive  displacements  most  regrettable,  in 
reference  to  the  preservation  of  the  shape  and  the  usefulness 
of  the  limb.  A  last  reason  for  the  employment  of  an 
apparatus  is  that,  whilst  rendering  the  dressing  easy,  it  at 
the  same  time  safeguards  the  limb  from  any  circular  con- 
striction which  would  be  unfavourable  to  its  vitality. 

Complete  fractures  of  the  ulna  generally  show  less  dis- 
placement than  those  of  the  radius. 

Treatment. — Immediate  immobility  of  the  forearm  can 
be  obtained  by  a  sling,  by  any  splint,  by  bandages  with  a 
straw  splint. 

We  must  be  careful  in  applying  the  dressing  not  to  exert 
too  strong  a  circular  or  interosseous  constriction,  as  this 
might  cause  gangrene. 

Immobilization  should  be  obtained  with  the  forearm  in 
the  position  of  supination;  the  fragments  then  will  be  in 
good  position.  In  half  pronation  or  in  complete  pronation, 
these  fragments  cross  one  another,  and  their  extremities 
are  directed  towards  the  axis  of  the  interosseous  space 
(Ferraton). 

Our  hollowed  out  metallic  splint  with  valves  insures  the  easy 
application  of  the  dressings,  it  enables  us  to  exercise  super- 
vision, to  push  back  towards  the  axis,  if  necessary,  the 
lateral  splinters  when  they  are  displaced  from  the  centre, 
besides,  in  our  hollowed  out  splint,  supination  is  the 
natural  position. 

The  splint  should  be  long  enough  to  include  part  of  the 
arm  and  the  hand,  so  as  to  immobilize  both  the  elbow  and 
the  wrist. 

Antero-posterior  or  lateral  deviations  (the  last  are  the  most 
serious,  especially  of  the  ulna)  are  the  result  of  the  frag- 
ments over-riding,  and  should  be  prevented.  Pseud- 
arthrosis  exposes  the  limb  to  the  same  danger,  and  pseud- 
arthroses  are  not  rare  in  the  forearm.  They  are  nearly 
always  consecutive   to   unjustifiable  removal  of  splinters, 


206  WOUNDS  OF  THE  UPPER  LIMBS 

therefore  we  must  absolutely  abstain  from  doing  this,  at 
least  at  first. 

In  fractures  of  both  the  radius  and  the  ulna,  as  a  conse- 
quence of  the  isolated  synostosis  of  the  upper  fragments, 
then  of  the  lower,  the  movements  of  pronation  and  of 
supination  are  lost. 

In  order  to  reach  wounded  vessels  we  must  make  use  of 
the  classical  incisions.  They  should  also  be  utilized  in 
searching  for  foreign  bodies,  and  in  opening  purulent  col- 
lections. 

Conservatism  must  he  pushed  to  its  extreme  limits.  This  is 
the  occasion  to  repeat  that  whatever  the  extent  of  a  traumatism 
due  to  a  bullet^  conservatism  should  he  carried  out  as  long  as  there 
is  no  confirmed  gangrene. 

Prognosis  is  generally  very  good,  even  when  the 
fracture  is  of  a  complicated  type.  For  this  reason  we 
should  most  carefully  endeavour  to  obtain  a  perfect  ulti- 
mate result. 

We  need  not  stop  to  consider  the  consecutive  nervous 
and  osseous  complications. 

Wounds  of  the  Elbow. 

The  elbow  is  the  region  comprised  between  two  trans- 
verse lines  passing  at  two  fingers'  breadths,  4  centimetres 
above  and  below  the  fold  of  flexion. 

Its  wounds  represent  one-tenth  of  the  lesions  of  the  upper 
limb,  and  3  per  cent,  of  the  total. 

The  tracks  of  the  bullets  that  reach  it  are  nearly  always 
antero -posterior,  more  rarely  postero -anterior  or  transverse. 

Wounds  of  the  Soft  Parts.— The  only  point  of  interest 
in  wounds  of  the  soft  parts  lies  in  lesions  of  the  vessels, 
haemorrhage  from  the  brachial,  from  its  venae  comites,  from 
the  superficial  veins,  and  in  lesions  of  the  nerves  (median, 
ulnar,  radial). 

The  classical  incision  for  ligature  brings  the  surgeon  on 


WOUNDS  OF  THE  ELBOW  207 

to  the  brachial  artery.  If  it  has  been  divided,  the  only 
efficacious  plan,  in  order  to  prevent  blood  coming  back 
through  the  inferior  end,  is  to  ligature  both  ends. 

Osseous  Lesions. — Osseous  lesions  should  be  studied 
on  every  bone  of  the  part. 

With  reference  to  the  elbow,  as  in  dealing  with  all  joints, 
we  have  concisely  laid  down  what  damage  is  caused  by 
bullets  on  the  extremity  of  the  JmmeniSy  on  the  radius,  and  on 
the  idna* 

On  the  epicondyle  and  epitrochlea,  which  are  but  super- 
added epiphyses,  the  grooves,  perforations,  and  abrasions  that 
we  see  are  limited  lesions. 

On  the  trochlea  and  the  condyle,  the  damage  caused  by 
bullets  whose  track  is  situated  below  the  epicondylo-condylar 
line  is  limited.  It  is  rare  for  this  damage  to  extend  above 
this  line.  With  regard  to  the  nature  of  the  lesions,  they 
are  clean  fractures,  furrows,  perforations,  abrasions  ;  the  perfora- 
tions are  nearly  always  not,  or  but  little,  comminuted. 
From  transverse  fire  the  lesions  are  more  important. 
Generally  they  are  simple. 

When  the  bullet  penetrates  on  the  level  of  the  epitrochlear- 
epicondylar  line  or  below  it,  the  lesion  is  of  the  epiphysial- 
diaphysial  type — that  is  to  say,  the  perforation  is  accom- 
panied by  more  or  less  complete  fissured  tracts,  which  are 
prolonged  as  much  as  5,  6,  7  centimetres  above  the  inter- 
vening line,  forming  nearly  always  two  lateral  splinters, 
which,  lower  down,  enclose  a  large  subperiosteal  adherent 
fragment  represented  by  the  condyle  and  the  trochlea. 
The  fracture,  whether  incomplete  or  complete,  is  there- 
fore supracondylar.  A  secondary  fissured  tract  may  make 
it  supra-  and  inter-condylar. 

On  the  other  hand,  if  the  firing,  instead  of  being  median, 
is  lateral,  only  one  fissure  is  found  which  limits  an  adherent 
internal  or  external  condylar  fragment. 

*  E.  Delorme,  Treatise  on  War  Surgery,  p.  296  et  seq. 


2o8  WOUNDS  OF  THE  UPPER  LIMBS 

A  bullet  that  penetrates  to  the  limit  of  the  olecvanial  and 
coronoid  cavities — that  is  to  say,  to  two  fingers'  breadths  from 
the  epitrochlear-condylar  line — causes  a  typical  diaphysial 
fracture. 

The  head  of  the  radius,  the  coronoid  process  of  the  ulna,  the 
upper  half  of  the  olecranon,  are  composed  of  pure  superadded 
epiphysial  tissue.     Their  lesions  are  limited. 

The  bullet  that  penetrates  below  the  head  of  the  radius 
to  the  base  of  the  olecranon,  and,  a  fortiori,  below  it,  gives 
rise  to  one  or  two  radiating  cuneiform  fissures,  with  a 
superior  base  and  an  apex  descending  to  3  centimetres 
below  the  intervening  line. 

Diagnosis. — The  diagnosis,  clinically  based  on  the  re- 
lations of  the  track  to  the  osseous  extremities  with  which 
the  projectile  comes  into  contact,  is  at  first  easy,  before  the 
rapid  swelling  that  comes  on  in  this  region  has  set  up.  But 
it  is  necessary,  in  order  that  the  diagnosis  may  be  precise, 
for  the  two  segments  of  the  elbow  to  be  replaced,  at  any 
rate  in  the  surgeon's  mind,  in  the  position  they  occupied  at 
the  moment  of  the  traumatism.  Pain,  revealed  by  pressure 
on  the  course  of  the  fissures,  is  a  good  sign.  Radiography 
will  complete  the  first  data. 

Treatment. — All  bony  lesions  of  the  elbow,  when  caused  by 
bullets,  should  be  treated  at  first  by  conservatism,  whatever  be 
the  comminution,  whatever  the  extent  of  the  damage  to  the 
soft  parts,  even  if  the  brachial  artery  is  involved  and  the 
nerves  contused.  We  have  proved  this  in  an  admirable 
example  we  brought  before  the  Academy  of  Medicine. 

At  first  a  sling,  a  short  time  afterwards  a  hollowed  out 
valvular  metallic  splint,  which  takes  as  points  of  support 
the  arm  above  and  the  forearm  below,  leaving  the  elbow 
free,  will  insure  immobilization.  A  plaster  apparatus  is  not 
as  advantageous  as  this  splint.  It  is  more  prudent  to 
secure  this  immobilization  even  when  there  is  no  abnormal 
mobility. 


WOUNDS  OF  THE  ELBOW  209 

Superficial  antisepsis  with  immobility  generally  suffices 
to  secure  recovery.  When  there  is  suppuration,  the  neces- 
sary incisions  must  be  made  at  once. 

Superficial  and  anterior  abscesses  are  opened  by  the  in- 
cision that  is  utilized  for  ligature  of  the  brachial  artery, 
posterior  ones  by  an  axial  incision,  which,  if  necessary,  will 
also  open  the  bursa  of  the  olecranon,  where  suppuration  is 
often  started  by  a  slight  lesion. 

To  get  to  the  joint  we  must  have  recourse  to  a  posterior, 
median,  supra-olecranial  incision,  or  to  a  lateral  internal 
short  incision  skirting  the  inner  border  of  the  triceps  and 
stopping  below  at  the  epitrochlea,  so  as  not  to  wound  the 
ulnar  nerve  ;  finally,  to  the  lateral  external  curved  incision  - 
used  for  resection. 

Removal  of  perfectly  free  and  infected  fragments  can  be 
accomplished  through  these  incisions,  and  drainage  can  be 
established  from  one  wound  to  the  other. 

If,  by  reason  of  the  grave  nature  of  the  lesions  and  the 
slowness  of  the  cure,  we  apprehend  ankylosis,  the  limb  must 
be  placed  in  a  position  of  flexion  at  a  slightly  acute  angle, 
in  preference  to  a  barely  acute  one  or  to  a  right  angle 
(Ferraton).  The  first  position  is  the  only  one  that  allows 
the  patient  to  carry  his  hand  freely  to  his  mouth.  The 
forearm  will  be  in  a  position  midway  between  pronation 
and  supination ;  the  hand  should  have  the  thumb  upwards. 

Ankylosis  is  relatively  frequent  after  bullet  wounds,  for 
the  elbow  is  a  very  tight  ginglymus  that  stiff'ens  quickly, 
and  rapidly  loses  its  action  without  passive  movements. 
Therefore,  when  there  is  no  suppuration,  we  must  not  wait 
too  long  before  beginning  these  movements. 

Atypical  resection  should  be  exceptional ;  it  must  only 
be  undertaken  at  a  subsequent  period  if  there  is  prolonged 
osteitis. 


14 


2IO  WOUNDS  OF  THE  UPPER  LIMBS 

Wounds  of  the  Arm. 

From  the  elbow,  whose  limits  we  have  given,  the  region 
of  the  arm  extends  above  to  a  horizontal  line  which  should 
just  touch  the  inferior  border  of  the  pectoralis  major. 

Wounds  of  the  arm,  like  those  of  the  forearm  and  of  the 
elbow,  are  sometimes  isolated,  sometimes  complicated  by 
simultaneous  lesions  of  the  neighbouring  parts — the  head, 
the  thorax,  the  abdomen. 

Wounds  of  the  soft  parts  do  not  call  for  any  special 
practical  consideration.  They  are  sometimes  extensive 
both  in  front  and  behind  the  limb  when  caused  by  large 
shell  fragments. 

Osseous  lesions  of  the  diaphysis  of  the  humerus  are 
typical.  They  are  contusions  ;  longitudinal  fissures  ;  fractures 
by  contact^  either  transverse  or  oblique,  with  large  splinters ; 
grooved  fractures,  with  their  well-known  fissures ;  fractures  by 
perforation,  of  which  the  type  with  two  lateral  splinters, 
more  or  less  subdivided,  is  habitual.  In  this  last  lesion  the 
focus  of  free  splinters,  that  are  generally  short,  usually 
corresponds  to  the  bony  focus  of  exit,  and  extends  but 
little. 

Splinters  adherent  to  the  periosteum  are  from  6  to  8  centi- 
metres long.  The  close  relationship  of  the  musculo-spiral 
nerve  (in  French,  radial)  to  the  diaphysis  of  the  humerus  is 
the  cause  of  this  nerve  often  being  contused  or  torn  in  the 
fractures. 

Treatment. — Conservatism  is  the  rule  in  all  fractures  of  the 
humerus  by  bullets. 

If  immobilization  is  well  insured  by  Champenois's 
hollowed  out  splint,  or  by  a  hollowed  out  metallic  splint 
framed  on  Hennequin's  model,  it  will  be  found  that  applica- 
tion and  renewal  of  the  dressings  with  these  apparatus  are 
less  easy  than  with  the  hollowed  out  valvular  metallic  splint. 
Preference,  then,  should  be  given  to  this  last  apparatus 


WOUNDS  OF  THE  ARM  211 

In  some  fractures  of  the  upper  fourth  of  the  humerus,  in 
which  one  has  but  little  power  over  the  superior  fragment, 
as  it  has  a  tendency  to  abduction,  reduction  and  regular 
maintenance  of  reduction  is  only  obtained  by  also  giving 
the  inferior  segment  an  inclination  to  abduction.  This 
position  is  maintained  by  a  big  triangular  pad  fixed  against 
the  thorax,  with  its  apex  in  the  axilla,  and  against  which 
the  apparatus  and  splints  rest.     These  cases  are  rare. 

In  complete  fractures  of  the  lower  part,  the  point  of  the 
inferior  fragment  has  often  a  tendency  to  fall  forwards.  The 
fracture  is  reduced  by  a  localized  external  compression. 

In  the  largest  majority  of  cases,  maintenance  of  the 
reduced  fracture  in  an  axial  apparatus  will  suffice,  for  the 
displacement  of  the  fragments  is  either  non-existent,  or  very 
moderate  and  easily  reduced. 

Whether  the  axial  or  lateral  displacements  are  to  be 
reduced  or  are  non-existent,  the  whole  limb  must  not  be 
too  much  moved. 

The  lateral  splinters^  the  free  splinters,  must  not  be  re- 
moved at  once,  but  should  be  carefully  brought  nearer  the 
extremities  of  the  fragments,  whilst  resting  in  the  apparatus, 
through  pressure  exerted  by  elastic  tampons  of  cotton-wool 
applied  perpendicularly  to  the  course  taken  by  the  projectile. 
Repeated  radiographic  examination  will  give  the  requisite 
information  on  the  result  obtained,  and  on  the  one  that  we 
must  still  hope  for. 

When  the  wound  is  properly  treated  and  suppuration 
has  been  trivial,  recovery  is  generally  very  rapid — often  it 
is  obtained  in  nearly  as  short  a  time  as  would  be  necessary 
for  the  consolidation  of  a  simple  fracture. 

In  infected  foci  purulent  collections  should  be  at  once 
opened  by  lateral  incisions — either  the  internal  incision  along 
the  internal  border  of  the  biceps  is  employed,  or  the  external 
incision  along  the  external  border  of  the  triceps.  The 
musculo-spiral  must  be  avoided. 


212  WOUNDS  OF  THE  UPPER  LIMBS 

We  have  nothing  special  to  say  with  regard  to  lesions  of 
the  arteries  or  of  the  nerves,  to  aneuryms,  to  liberation  of 
the  musculo-spiral,  which  is  so  often  included  in  callus, 
to  the  removal  of  foreign  bodies,  to  foci  of  persistent  osteitis 
which  we  get  at  by  lateral  incisions  carried  to  the  level  of 
the  intermuscular  septa.  Let  us  remind  surgeons  that  the 
external  incision,  in  order  to  avoid  the  musculo-spiral,  must 
stop  below  at  lo  centimetres  from  the  epicondyle,  and  also 
that  subsequent  ligature  of  arteries  generally  necessitates 
free  incisions. 

Wounds  of  the  Shoulder. 

Wounds  of  the  Soft  Parts. — Amongst  the  wounds  of 
the  shoulder  we  only  have  now  to  study  those  in  the  region 
of  the  deltoid,  of  the  axilla,  and  of  the  articulation.  Lesions 
of  the  clavicle  and  of  the  body  of  the  scapula  have  been 
described  in  the  chapter  on  wounds  of  the  chest. 

2*9  per  cent,  of  the  wounded  men  are  hit  in  the  shoulder. 

Bullet  wounds  of  the  axillary  or  deltoid  regions  present 
nothing  in  particular.  Fragments  of  large  projectiles  some- 
times give  rise  in  these  localities  to  very  extensive  loss  of 
substance,  without,  however,  opening  the  joint. 

Opening  of  the  large  subdeltoid  serous  bursa  is  of  no 
importance  so  long  as  the  wound  remains  aseptic.  When 
it  is  infected  (shrapnel  bullets,  shell  fragments,  deflected 
bullets),  a  rapidly  developed  abscess  is  the  result. 

A  bullet  may  pass  between  the  acromion  and  the  articula- 
tion without  opening  the  joint. 

We  should  only  be  saying  the  same  things  over  again  if 
we  dwelt  on  the  characteristics  and  the  prognosis  of  lesions 
of  the  axillary  artery  and  vein.  These  large  vessels  give 
rise  to  formidable  primary  and  secondary  haemorrhage,  to 
arterial  and  arterio-venous  haematomata,  that  necessitate, 
in  the  hands  of  an  experienced  surgeon,  subsequent  difficult 


WOUNDS  OF  THE  SHOULDER  213 

operations.  Primary  or  secondary  hsemorrhage  must  be 
treated  by  direct  ligature.  Indirect  ligature  of  the  sub- 
clavian fails  in  two-thirds  of  the  cases. 

The  nerves  of  the  brachial  plexus,  the  circumflex  nerve, 
are,  like  the  important  arteries,  either  wounded  separately 
or  at  the  same  time  as  the  bones. 

Osseous  Lesions. —  On  the  superior  extremity  of  the 
humerus,  the  growing  or  epiphysial  cartilage,  that  differenti- 
ates lesions  of  the  head  of  the  bone  from  those  of  the 
remainder  of  the  articular  extremity,  corresponds  to  the 
anatomical  neck.  The  tuberosities  are  superadded  parts 
that  are  developed  from  special  bony  points,  and  that  retain 
their  individuality  with  regard  to  their  wounds. 

Head  of  the  Humerus. — i.  Bullets  that,  above  the 
cartilage  of  the  anatomical  neck,  reach  the  head  of  the 
humerus,  cause  furrows,  hollowing  otd,  simple  perforations,  or 
may  break  it  up.  This  last  is  rare,  but  even  in  such  cases 
the  fragments  remain  in  contact. 

2.  If  the  projectile  penetrates  at  the  level  of  the  anatomical 
neck,  about  its  centre,  the  head  of  the  bone  is  separated 
from  the  shaft  by  a  fissure,  but  nevertheless  it  remains  very 
adherent,  thanks  to  the  fasciculi  of  fibrous  tissue  about  it 
and  the  periosteum. 

3.  If  the  penetration  of  the  bullet  has  taken  place  near 
the  greater  ttiherosity.  This  latter  is  separated  by  a  wedge- 
shaped  fissure,  with  the  base  uppermost,  but  the  fragment, 
which  has  fixed  limits,  is  very  adherent. 

4.  Under  the  anatomical  neck,  on  the  surgical  neck,  the  lesion 
is  epiphysial-diaphysial ;  the  fissures  may  be  extended. 

5.  The  greater  tuberosity  is  excavated  as  by  a  groove, 
superficially  perforated  or  deeply  perforated.  The  lesion 
is  limited  to  the  tuberosity  when  the  firing  has  been  antero- 
posterior. If  it  has  been  transverse,  the  bullet  has  followed 
an  epiphysial-diaphysial  track,  and  has  led,  on  the  head  of  the 


214  WOUNDS  OF  THE  UPPER  LIMBS 

bone  and  on  the  diaphysis,  to  the  formation  of  two  large 
lateral  splinters. 

6.  The  lesser  tuberosity  may  be  abraded. 

Glenoid  Cavity. — In  the  glenoid  cavity  we  observe 
furrows,  simple  or  fissured,  perforations.  The  fragments 
are  nearly  always  held  in  place  by  the  insertions  of  the 
capsule. 

Diagnosis. — Lesions  of  the  shoulder -joint,  by  reason  of 
the  great  thickness  of  the  soft  parts  covering  it,  and  of  the 
extensive  swelling  which  sometimes  very  rapidly  invades 
the  region,  should  be  diagnosed  especially  by  taking  into 
account  the  seat  of  the  wounds  and  their  relationship  to  the 
points  occupied  by  the  extremity  of  the  humerus  and  by 
the  epiphysial -diaphysial  line.  Wounds  of  the  glenoid  cavity 
can  only  be  suspected  without  the  help  of  radiography. 

We  have  given  very  precise  data  for  insuring  the  diag- 
nosis of  lesions  of  the  upper  end  of  the  humerus. 

In  Front. — By  moderately  strong  pressure  we  can  re- 
cognize the  tip  of  the  covacoid  process  in  the  deltoid-pectoral 
space.  From  this  tip  we  drop  a  vertical  line.  The  inferior 
limit  of  the  anatomical  neck  of  the  hnmerus  is,  oft  this  vertical 
line,  a  finger's  breadth  below  the  coracoid  tip  and  a  little  internal 
to  it. 

If  from  the  most  prominent,  the  most  external,  part  of  the 
acromion  we  draw  a  line  which  ends  at  the  point  previously 
fixed,  the  resulting  oblique  line  gives  the  direction  and  the 
seat  of  the  anatomical  neck. 

With  the  arm  falling  vertically,  we  can  make  out  the 
rounded  head  of  the  humerus  above  this  line ;  the  lesser 
tuberosity  and  the  diaphysis  are  below  it. 

At  the  Back. — If  we  unite  the  same  acromial  point  to  the 
prominent  angle  of  the  scapula,  with  the  arm  falling  vertically, 
we  mark  out  the  line  of  the  anatomical  neck. 

Its  inferior  limit  is  where  the  preceding  line  intersects  a  vertical 
line  dropped  from  the  acromio -clavicular  articulation,  which  can 


WOUNDS  OF  THE  SHOULDER  215 

be  recognized  by  the  prominence  of  the  outer  extremity  of 
the  clavicle. 

If  the  line  of  the  neck  be  carried  backwards,  we  make 
out,  above  it  the  head,  and  below  it  the  remainder  of  the 
humerus,  in  the  same  way  as  in  front. 

With  these  data,  confirmed  by  radiography,  it  is  easy  to 
recognize  the  bony  points  that  have  been  wounded.  Our 
anatomical  and  pathological  knowledge  will  indicate  the 
character,  the  limits,  and  the  extension  of  the  lesions. 

Treatment.  —  Conservatism  is  the  rule  in  lesions  of  the 
shoulder.  It  is  primarily  applicable  in  neavly  all  injuries  caused 
by  bullets,  even  in  the  most  serious  ones. 

Amputation  would  only  be  justifiable  in  confirmed  gangrene. 
Immobility  is  at  first  obtained  by  a  sling  and  by  fixing  the 
arm  to  the  body.  Subsequent  immobility  and  keeping  in 
position  necessitate  the  employment  of  other  methods.  A 
hollowed  out  splint  is  one  of  the  best  apparatus. 

The  ordinary  hollowed  out  splints  made  of  iron  wire  are 
detestable ;  their  equilibrium  is  unstable,  they  get  out  of 
place,  forcing  the  patient  to  stiffen  himself  to  keep  them 
from  falling  off,  or  to  constantly  hold  them  up  with  his 
hand ;  besides,  they  do  not  allow  an  easy  application  of 
dressings.  Hennequin's  hollowed  out  plaster  splint,  Cham- 
penois's  splint,  and,  above  all,  our  hollowed  otit  splint  with 
valves,  lengthened  out  when  necessary,  in  certain  cases,  in 
order  to  cover  over  the  whole  shoulder,  are  preferable. 

Extension  is  necessary  in  some  fractures  of  the  surgical 
neck,  but  these  cases  are  rare.  Our  apparatus,  which 
exerts  counter-extension  in  the  axilla  and  extension  on  the 
elbow,  realizes  these  desiderata  with  great  simplicity.  A 
few  notches  are  made  in  the  part  of  its  upper  edge  which 
rests  in  the  axilla  ;  the  flaps  thus  formed,  that  correspond 
to  the  armpit,  are  evenly  turned  down  and  well  padded. 
A  spica  bandage  of  the  neck  and  the  axilla  is  then  put  on  ; 
it  firmly  fixes  the  apparatus  above,  and  gives  it  a  power  of 


2i6  WOUNDS  OF  THE  UPPER  LIMBS 

counter-extension.  Extension  is  made  on  the  elbow  by- 
bandages. 

In  infected  wounds,  abscesses  under  the  deltoid  must  be 
opened  in  front  by  the  anterior  vertical  deltoid  iitcision  used  in 
excision,  carried  a  little  outside  the  deltoid  pectoral  line. 
Behind  a  symmetrical  incision  may  be  made,  but  it  must 
not  descend  more  than  4  centimetres  below  the  acromion, 
so  as  to  avoid  wounding  the  circumflex  nerve. 

Collections  of  pus  in  the  axilla  are  incised  behind  the 
inferior  border  of  the  pectoralis  major  ;  periscapular  col- 
lections along  the  spinal  border  of  the  scapula,  and  the 
incision  is  followed,  when  necessary,  by  freeing  of  the  bone 
with  the  finger. 

Removal  of  splinters  that  cause  intolerable  suffering  will 
be  done  through  the  same  routes. 

Atypical  excision  is  quite  allowable,  but  only  at  a  future 
period  and  in  cases  of  persistent  osteitis. 

The  grave  disturbances  caused  by  shell  fragments  may 
necessitate  a  disarticulation.  We  must  bear  in  mind  that  a 
disarticulation  of  the  shoulder  can  be  done  by  placing  the 
knife  almost  exactly  under  the  acromion  (Ledran),  and  in 
this  way  that  an  excellent  stump  can  be  made.  The  typical 
intrascapular  thoracic  disarticulation  is,  so  to  speak,  never 
indicated. 


CHAPTER  XXI 

WOUNDS  OF  THE   LOWER   LIMBS 

Lesions  of  the  lower  limbs  are  about  two-thirds  of  the 
total  wounded  (Ferraton). 

Wounds  of  the  Soft  Parts. 

Before  speaking  of  the  wounds  caused  by  weapons  used 
in  warfare,  let  us  call  attention  to  the  oedema  seen  in  men 
who  are  obliged  to  keep  on  their  bandages  (puttees)  for  too 
long  a  time  ;  also  to  the  ulcerated  blisters  on  the  sole,  on  the 
posterior  part  of  the  foot,  regions  that  correspond  to  the 
tendo  Achillis,  to  the  malleoli,  these  excoriations  being  so 
frequent  that  formerly  at  the  beginning  of  a  campaign  it 
was  admitted  that  a  fifth  of  the  strength  of  an  army  was 
rendered  unavailable  through  this  cause.  When  badly 
treated,  these  excoriations  give  rise  to  reticular  lymphangitis 
of  the  foot,  which  extends  to  the  leg,  and  is  too  often 
followed  by  abscesses  and  diffuse  putrid  phlegmonous 
inflammation.  Military  surgeons  cannot  pay  too  much 
attention  to  the  question  of  these  complications,  which 
cleanliness  of  the  feet,  inunction  with  some  fatty  body, 
employment  of  alum,  formol,  picric  acid,  or  iodine,  may 
prevent  or  mitigate. 

We  may  also  mention  peritendinous  cellulitis  of  the  tendo 
Achillis  and  twisted  foot — which  is  only  a  metatarsal  fracture 
(Pauzat). 

217 


2i8  WOUNDS  OF  THE  LOWER  LIMBS 

The  foot  is  very  frequently  hit  by  projectiles,  as  often  as 
the  thigh. 

The  track  is  dovsi -plantar,  planti-dorsal,  or  transverse. 

Lesions  of  the  Bones — Toes. — Notwithstanding  their 
small  size,  the  toes  are  diaphysial  bones.  Their  epiphysis 
may  be  hollowed  out  into  a  groove  or  perforated.  When 
the  diaphysis  is  hit,  the  groove  and  perforation  are  clean, 
or  may  be  prolonged  by  fissures.  These  lesions  are  very 
small,  even  when  present  simultaneously  on  several  toes. 

The  METATARSALS  are  diaphysial  long  bones  with  very 
compact  tissue.  Their  lesions  show  on  the  body  of  the 
bone  the  classical  characteristics  of  transverse  and  oblique 
contact  fractures.  They  are  very  frequent.  Grooves  are 
found,  also  perforations  of  the  usual  type  with  lateral  splinters. 
The  free  splinters  are  small ;  the  adherent  ones  are  only 
2,  3,  4  centimetres  long.  In  transverse  fire,  several  meta- 
tarsals, specially  those  at  the  extremity  of  the  arch  of  the 
foot,  are  fractured.  Subdivision  of  the  splinters  is  greater 
in  the  last  bones  hit.  The  metatarsal  epiphysial  extremities 
present  typical  epiphysial  lesions,  without  splinters. 

The  BONES  OF  THE  TARSUS,  in  spite  of  the  variety  in  their 
shape,  present  grazes,  furrows,  tunnelling  —  regular  canals 
without  fissures  or  noticeable  splinters. 

By  reason  of  its  size,  its  structure  of  oblique  fibres 
directed  from  below  and  from  the  back  of  the  bone,  we  see 
in  the  os  calcis  tunnellings  often  accompanied  by  radiating 
open  fissures,  or  rather  fissures  directed  in  an  oblique  way 
with  regard  to  its  fibres.  The  splinters  limited  by  these 
fissures  are  generally  adherent.  We  will  deal  later  on  with  the 
lesions  of  the  astragalus. 

Diagnosis. — The  diagnosis,  based  on  the  relations  of  the 
track  to  the  bones  it  meets,  is  usually  easy  to  the  surgeon 
who  is  well  acquainted  with  the  anatomy  of  the  foot.  It  is 
afterwards  completed  by  radiography. 

Complications. — Wounds  of  the  foot  possess  but  little 


WOUNDS  OF  THE  SOFT  PARTS  219 

surgical  interest  excepting  through  their  complications — 
hemorrhage,  foreign  bodies,  infection,  tetanus. 

Hemorrhage  comes  from  the  dorsalis  pedis  artery  or  from 
the  two  plantar  vessels,  especially  from  the  external,  which 
is  larger  and  longer  than  the  internal.  The  dorsalis  pedis 
has  a  well-known  course.  That  of  the  plantar  arteries  is 
not  so  familiar.  We  have  already  described  it,  and  we  will 
again  call  it  to  mind. 

If,  on  the  sole  of  the  foot,  we  draw  (i)  a  vertical  line 
starting  from  a  point  on  the  centre  of  the  heel,  and  going 
to  the  interdigital  space  that  separates  the  fifth  from  the 
fourth  toe,  and  (2)  a  line  starting  from  the  inner  fourth 
of  the  heel,  and  going  to  the  first  interdigital  space,  these 
lines  will  give  the  direction  of  the  two  intermuscular  septa, 
internal  and  external.  Now,  these  septa  divide  the  sole  into 
three  parts — the  external,  the  middle,  and  the  internal. 

The  external  part  contains  no  important  vessels. 

In  the  internal  part  runs  the  internal  plantar  artery,  which 
becomes  unimportant  after  reaching  the  metatarsus. 

In  the  middle  part,  the  external  plantar  describes  a  curve 
with  an  external  convexity,  which  terminates  at  the  bases 
of  the  central  metatarsal  bones.  The  result  of  this  arrange- 
ment is  that  the  external  part  and  the  metatarsal  region 
can  be  traversed  without  danger  to  any  important  vessels, 
and  that,  with  regard  to  haemorrhage,  lesions  of  middle 
part,  and,  in  some  measure,  of  the  internal  part,  are  the 
only  ones  to  take  into  consideration. 

A  deep  incision,  of  an  appropriate  length,  which  pushes 
aside  the  flexor  brevis  digitorum  immediately  inside  the 
external  intermuscular  septum  in  the  region  of  the  tarsus, 
allows  us  easily  to  find  the  external  plantar  artery  and  to 
ligature  it.     (External  plantar  incision,  Delorme.) 

A  tarsal  incision  inside  the  internal  intermuscular  septum 
allows  us  to  find  the  internal  plantar  and  ligature  it. 
(Internal  plantar  incision,  Delorme.) 


220  WOUNDS  OF  THE  LOWER  LIMBS 

A  skilled  surgeon  will  utilize  these  direct  incisions  to 
put  an  end  to  plantar  hsemorrhage.  Others  will  employ 
immediate  compression  after  incision  or  mediate  compres- 
sion without  incision,  haemostatic  proceedings  that  are 
rendered  very  useless  by  the  wealth  of  anastomosis  in  the 
part. 

The  exploratory  incisions  we  have  described  govern  all 
the  necessary  surgery  to  deal  with  complications  in  wounds 
of  the  foot.  They  lay  bare  the  vessels ;  they  enable  us  to 
search  for  metallic  foreign  bodies ;  they  also  give  an  outlet 
to  the  discharge  of  plantar  abscesses,  almost  exclusively 
localized  in  the  middle  part,  before  described,  and  which 
are  pretty  frequent  owing  to  the  dirt  on  the  sole  of  the 
foot  and  on  the  pieces  of  the  patients'  socks  and  boots,  these 
fragments  having  been  carried  into  the  wound,  owing  also 
to  the  sheaths  of  the  tendons  having  been  opened  (deflected 
bullet,  shrapnel  bullet).  Again,  it  is  by  the  help  of  these 
incisions  that  we  remove  splinters  that  have  been  forced 
forward  and  are  badly  tolerated.  They  are  the  result  of  a 
bullet  with  a  dorso-plantar  track. 

Tetanus  is  a  rather  frequent  complication  of  these  wounds. 

Treatment. — Wounds  of  the  foot  very  often  end  in 
recovery,  and  this  is  nearly  always  brought  about  by  simple 
treatment — application  of  dry  dressing,  rendered  antiseptic 
by  iodine — and  immobilization.  Wet  dressings  must  never 
be  applied.     On  the  foot  they  are  absolutely  pernicious. 

The  dressings,  if  they  are  thick  enough,  will  themselves 
insure  immobilization.  It  is  only  when  the  firmness  of  the 
foot  is  jeopardized  by  an  extensive  fracture  that  we  should 
have  recourse  to  an  immobilizing  apparatus. 

A  very  bad  practice,  and  one  that  is  too  much  followed, 
consists  in  letting  these  patients  walk  whilst  they  are  suffer- 
ing from  bone  lesions  of  the  foot.  Their  cure  is  thereby 
much  retarded,  and  they  are  thus  exposed  to  complications. 
All  walking  on  the  wounded  foot  should  be  forbidden  for  a 


WOUNDS  OF  THE  INSTEP  221 

long  time,  but  this  does  not  mean  that  the  surgeon  should 
abstain  from  utilizing  passive  movement. 

Amputation  is  only  admissible  at  first  as  a  standard  opera- 
tion in  very  vast  shattering  transverse  lesions  the  result  of 
shell  fragments.  The  technique  of  these  operations  can  be 
simplified  if  the  foot  is  considered  as  being  formed  of  only 
one  bone  (Mayor). 

Although  primary  conservatism  miist  he  the  rule,  we  must 
not  hesitate  at  a  later  date  to  rid  the  patient  of  deflected 
troublesome  toes,  and  even  of  the  foot,  if  it  has  become 
very  much  deformed,  and  inconveniences  the  man  when  he 
walks,  and  whose  deviations  we  have  been  unable  to  correct 
by  anastomosis  of  tendons,  by  tarsectomy,  or  by  arthrodesis 
(Syme's  operation). 


Wounds  of  the  Instep. 

From  the  subastragalar  articulation,  the  instep  extends 
to  3  centimetres  above  the  tibio-tarsal  interspace. 

Wounds  of  the  Soft  Parts.— Indentations,  perfora- 
tions of  the  tendo  Achillis  and  of  the  anterior  and  posterior 
tendons,  opening  of  their  sheaths,  wounds  of  the  anterior 
and  posterior  tibial  arteries  and  of  their  accompanying 
nerves,  represent  the  most  interesting  lesions  of  the  soft 
parts  of  the  instep. 

Large  shell  fragments  may  become  lodged  between  the 
tendo  Achillis  and  the  deep  parts. 

Lesions  of  the  Bones. —  The  astragalus  may  be 
eroded,  hollowed  otit  into  grooves,  or  perforated.  In  anterior- 
posterior  fire,  perforation  may  be  accompanied  by  separa- 
tion of  the  bone  into  two  parts.  In  transverse  fire  the  neck 
may  be  divided.  Fissures  of  the  remainder  of  the  bone 
are  vertical  or  radiating. 

Perforation  is  generally  clean,  and,  thanks  to  the  strength 
of  the  ligaments  that  are  inserted  into  three  of  the  surfaces 


222  WOUNDS  OF  THE  LOWER  LIMBS 

of  this  bone,  the  fractured  fragments  remain  in  contact, 
even  if  the  fissures  are  deep. 

On  the  TIBIAL  EXTREMITY  the  lesions  are  rarely  of  the 
epiphysial  type,  because  the  level  of  the  cartilage  of  growth 
is  only  a  centimetre  high.  So  that  in  the  perforations,  which 
are  the  usual  lesions,  fissures  are  often  seen,  although  they 
do  not  practically  complicate  the  traumatism.  These 
fissures  form  the  limitations  of  wedges  at  the  periphery  of 
the  bone,  or  else  are  radiated. 

The  EXTERNAL  MALLEOLUS  is  hollowed  out  as  with  a 
gouge  or  perforated.  At  i  centimetre  above  its  base  the 
lesion  takes  on  the  diaphysial  type.     It  is  always  simple. 

Diagnosis. — Generally,  diagnosis  is  easy,  in  spite  of  rapid 
and  sometimes  considerable  swelling.  It  is  based  on  the 
relationship  of  the  wound  to  the  articulation. 

Treatment.  —  Haemorrhage  from  the  tibial  arteries 
renders  compression  necessary,  then  ligature.  Suppura- 
tion that  has  a  synovial  origin  readily  diffuses  to  the  dorsal 
surface  of  the  foot,  to  the  anterior  surface  of  the  leg,  to  the 
plantar  region,  to  the  posterior  surface  of  the  leg.  Incisions, 
as  for  ligature  of  the  tibial  arteries,  or  our  external  plantar 
incision,  are  indicated. 

Primitive  conservatism  is  the  rule  in  osseons  lesions  of  the  instep 
by  bulletsy  and  we  may  call  its  indications  ahsolnte. 

Immediate  immobilization  is  obtained  by  the  wounded 
man's  boot ;  this  is  replaced  by  a  temporary  apparatus,  and 
finally,  as  soon  as  possible,  by  a  gutter-like  splint  with  a 
movable  plantar  portion  similar  to  that  in  Raoult  Deslong- 
champ's  hollowed  out  leg-splint  and  in  our  own  apparatus. 
We  cannot  imagine  employment  of  any  other  apparatus. 
In  any  case,  none  other  facilitates  to  the  same  extent  subse- 
quent inspection  of  the  limb,  application  of  dressings,  and 
performance  of  any  necessary  intervention. 

Vigilant  watching  of  a  region  so  easily  infected  as  that  of 
the  instep  should  be  incessant ;  the  same  may  be  said  with 


WOUNDS  OF  THE  INSTEP  223 

regard  to  the  foot.  On  the  first  threat  of  suppuration 
incisions  must  be  made  at  the  points  we  have  indicated. 

Suppurative  arthritis  will  be  treated  by  vertical  anterior 
incisions  following  the  borders  of  the  internal  and  external 
malleoH.  Infected  splinters  whose  presence  cannot  be 
tolerated  should  be  removed  through  these  incisions,  or 
through  those  of  astragalectomy. 

Primary  removal  of  splinters  is  condemned. 

In  those  cases  where  the  lesions  that  can  be  seen  give  us 
cause  to  fear  consecutive  deviation,  we  should  prolong  the 
immobilization  of  the  foot  in  a  good  position — that  is  to 
say,  in  flexion,  not  at  a  right  angle,  but  at  a  slightly  acute 
angle. 

Cure  of  bullet  wounds  of  the  instep  is  very  common,  and 
is  obtained  without  much  difficulty. 

Wounds  of  the  Leg. 

Wounds  of  the  leg  are  pretty  frequent.  Fractures  of  the 
leg  represent  a  quarter  or  a  third  of  all  fractures. 

Wounds  of  the  Soft  Parts — The  only  wounds  of 
this  kind  that  deserve  mention  are  extensive  setons,  the  culs- 
de-sac,  very  often  infected  and  giving  rise  to  abscesses  that 
must  be  opened  at  once,  or  we  risk  their  diffusion ;  finally, 
the  simple  perforations  of  the  interosseous  space,  with  wounding 
of  the  tibial  arteries  and  nerves. 

Antero-posterior  and  postero-anterior  bullet  wounds  do 
not  seem  much  more  frequent  than  the  transverse. 

Lesions  of  the  Bones. — The  fibula,  after  tangential 
fire,  often  exhibits  transverse  or  oblique  fractures. 

Nearly  always  on  this  bone  we  see  grooves  a.nd perforations. 
The  former  are  simple — that  is  to  say,  they  may  consist  of 
mere  notches  (indentations  of  the  edges),  or  they  may  show 
at  the  same  time  the  notch  and  a  transverse  or  oblique 
fracture,  or  one  with  long  splinters. 


224  WOUNDS  OF  THE  LOWER  LIMBS 

Perforations  with  adherent  splinters  4  to  6  centimetres 
long,  and  short,  free  splinters  are  common. 

Tibia. — On  the  tibia  we  may  see  with  remarkable  clear- 
ness all  the  varieties  of  diaphysial  lesions. 

Contusions  are  very  frequent.  On  the  inner  surface  of 
the  bone  they  are  evident. 

Longitudinal  fissures  may  groove  one  surface  or  the 
three  surfaces  of  the  bone. 

Transverse  and  oUiqiie  fractures  by  contact  are  seen  on  any 
part  of  the  bone,  but  specially  at  the  lower  third. 

Contact  fractures  with  large  splinters,  either  of  a  simple  or  a 
comminutive  type,  may  be  observed  at  all  parts  of  the  bone. 

Only  a  few  examples  are  cited  of  perforation  of  only  one 
side  of  the  bone.  The  most  usual  osseous  lesions  are 
grooves  ivith  adherent  splinters,  and  especially  through-and- 
through  perforation. 

The  type  of  perforation  is  always  the  same  whichever 
surface  of  the  bone  is  hit. 

The  adherent  splinters  of  the  perforation  are  often  a  third 
or  a  half  as  long  as  the  bone.  The  free  splinters  are 
relatively  large  and  big.  They  are  i,  2,  3  centimetres  in 
length. 

When  the  aperture  of  exit  corresponds  to  the  inner  surface 
of  the  tibia,  and  when  the  bullet  that  produced  the  lesion  has 
had  a  high  velocity,  the  burst  skin  presents  a  big  breach. 

Simultaneous  lesions  of  the  tibia  and  fibula  return  to  the 
usual  types.  The  second  bone  hit  presents  a  more  com- 
minuted fracture  than  the  other  bone. 

All  these  fractures  are  with  or  without  displacement. 
Generally  the  displacement  is  very  slight. 

Diagnosis. — The  diagnosis  is  easy,  and  can  be  estab- 
Ushed  by  the  help  of  the  ordinary  signs. 

Treatment. — Hemorrhage  and  hcematomata  are  frequent 
complications  (one-tenth)  of  wounds  of  the  leg.  Pushing 
forwards   of   the  splinters  is  not  unconnected  with  their 


WOUNDS  OF  THE  LEG  225 

frequency,  as  they  are  seen  fotir  times  more  often  in  cases 
of  fracture  than  in  wounds  of  the  soft  parts. 

Either  distant  or  mediate  compression  is  the  immediate 
treatment,  direct  ligature  the  surgical  treatment. 

When  uncertain  as  to  which  of  the  posterior  vessels  has 
been  damaged,  we  should  make  an  axial  incision  which 
will  allow  us  to  reach  both  the  posterior  tibial  and  the 
peroneal  arteries.  We  must  not  fear  to  freely  relieve  con- 
striction by  incisions,  and  here,  as  elsewhere,  we  must 
apply  ourselves  less  to  directly  recognize  the  vessel,  which 
is  masked  by  the  blood,  and  difficult  to  identify  and  to  take 
up  because  its  continuity  has  not  been  interrupted — than  to 
discover  the  accojnpanying  nerve.  Once  this  last  is  found,  the 
artery  can  easily  be  freed. 

Abscesses  should  be  opened  through  the  incisions  which 
would  be  employed  to  ligature  the  arteries. 

The  same  incisions  will  serve  also  in  the  subsequent 
search  after  deep  and  badly  iolexoXed  foreign  bodies. 

Immobilization  is  obtained  on  the  field  of  battle  by  fixation 
of  the  HEALTHY  leg  against  the  wounded  leg. 

A  good  temporary  apparatus  can  be  made  of  straw, 
covered  with  canvas,  and  used  as  bandages. 

Ultimate  apparatus  may  be  of  pasteboard,  plaster,  or 
zinc,  framed  on  Raoult  Deslongchamp's  model,  etc. ;  the 
best  undoubtedly  are  the  valvular  metallic  splints,  hollowed 
out  like  a  gutter.  Our  conviction  on  this  point  is  stronger 
than  ever.  The  use  of  these  splints  should  be  made  general. 
No  other  keeps  the  parts  in  such  good  apposition,  renders 
the  dressing  so  easy,  facilitates  the  bringing  together  of 
displaced  splinters  and  the  supervision  of  the  lirnb.  We 
have  witnessed  most  deplorable  displacements  in  fractures 
treated  in  hollowed  out  splints  of  iron  wire,  which  quite 
wrongly  are  very  much  used,  and  we  have  many  times 
verified  and  heard^  mentioned   the    difficulties   that   these 

15 


226  WOUNDS  OF  THE  LOWER  LIMBS 

splints  and  plaster  apparatus  make  the  surgeon  experience 
in^the  application  of  the  dressings. 

Apparatus  for  continuous  extension  can  only  very  rarely 
be  indicated,  and  those  to  aid  walking  are  not  often  of  use 
in  our  traumatisms. 

When  the  fibula  alone  is  wounded,  the  tibia  serves  as  a 
splint. 

We  must  do  our  best  to  obtain  very  satisfactory  definite 
results,  to  avoid  callus  with  angular  points  in  front  or  at 
the  back,  especially  lateral  deviations,  axial  rotation,  stiff- 
ness of  the  knee  and  of  the  instep.  We  must  make  a  point 
of  frequently  ascertaining  that  a  line  starting  from  the  first 
interdigital  space  cuts  through  the  centre  of  the  patella  to 
get  to  the  middle  of  Poupart's  ligament.  This  line  is  that 
of  the  limb's  normal  direction. 

We  will  not  speak  of  the  nervous  lesions  or  of  osteitis. 
Primitive  amputation  is  contra-indicated  in  bullet  wounds,  unless 
the  case  be  one  of  confirmed  gangrene. 

It  is  only  admissible  as  an  atypical  operation  to  deal  with 
a  large  wound  that  has  been  torn  by  shell  fragments,  and 
shows  lesions  of  the  vessels  and  of  the  nerves. 

Wounds  of  the  Knee. 

The  knee  is  comprised  between  an  inferior  transverse 
plane,  passing  through  the  anterior  tuberosity  of  the  tibia, 
and  a  superior  one  cutting  through  the  thigh  three  fingers' 
breadths  above  the  upper  border  of  the  patella. 

Traumatisms  of  the  knee  caused  by  projectiles  are  very 
frequent  (one-third  of  joint  wounds,  3  per  cent,  of  all 
wounds).  Penetrating  wounds  are  more  often  seen  than 
non-penetrating. 

Peri  -  articular  Wounds. — These  are  nearly  always 
posterior  lesions,  whose  gravity  consists  entirely  in  wounds 
of  the  large  popliteal  vessels  and  nerves. 

Wounds  of  the  popliteal  vessels  give  rise  to  very  severe 


WOUNDS  OF  THE  LEG  227 

immediate  haemorrhage  or  to  arterial  haematomata,  that 
endanger  the  hmb's  vitaHty  and  are  very  difficult  to  treat. 

Compression  at  a  distance  does  not  securely  arrest  the 
haemorrhage,  mediate  compression  is  prejudicial  to  the  col- 
lateral circulation.  Direct  ligature  is  the  sole  surgical  treat- 
ment ;  but  where  is  it  to  be  applied,  and  how  many 
surgeons  could  perform  the  operation  ?  All  these  conditions 
make  the  prognosis  of  these  wounds  essentially  gloomy. 

These  wounded  men,  threatened  with  gangrene ,  must  remain  on 
the  spot,  and  we  may  look  forward  to  have  to  perform 
amputation  of  the  thigh  after  a  very  short  delay,  so  soon  as 
we  see  the  first  signs  of  gangrene,  if  direct  ligature  is 
impossible. 

Popliteal  haematomata  are  sometimes  enormous  ;  they 
invade  the  whole  of  the  popliteal  space,  the  leg,  the  thigh, 
being  too  often  preliminary  to  gangrene  and  to  diffuse 
suppuration.  On  other  occasions  the  situation  is  quite 
different :  the  haematoma  is  circumscribed,  and  comes  on 
late  (arterial  contusion).  Direct  intervention,  to  be  of  use, 
must  treat  the  collateral  circulation  with  caution,  and  no 
dissection  should  be  carried  out. 

Wounds  of  the  internal  popliteal  nerve  that  involve  its 
whole  thickness  do  not  imperil  the  function  of  the  most 
important  muscles  of  the  leg,  whilst  the  foot,  that  does  not 
undergo  lateral  deviation,  can  be  very  useful  even  after 
complete  section  of  this  nerve.  Walking  is  quite  possible 
and  is  steady. 

Section  of  the  external  popliteal  nerve,  on  the  other  hand, 
gives  rise  to  very  much  greater  inconvenience,  yet  the 
patient  may  still  manage  to  walk  with  the  help  of  an  ortho- 
paedic boot  (Letievant). 

Wounds  of  the  Joint  without  Osseous  Lesions.— 
They  are  pretty  frequent,  and  are  produced  by  a  bullet 
penetrating  under  the  tendon  of  the  quadriceps,  going  across 
the  cul-de-sac  beneath  it,  perforating  the  articulation,  whilst 


228  WOUNDS  OF  THE  LOWER  LIMBS 

the  knee  is  flexed,  and  penetrating  in  the  middle  line  under 
the  apex  of  the  patella.  Such  are  the  most  common  simple 
articular  lesions. 

Wounds  of  the  Joint  with  Osseous  Lesions. — The 

borders  of  the  patella  are  indented,  its  surfaces  hollowed  out 
as  with  a  gouge  ;  the  bone  is  perforated  from  before  backwards 
or    transversely,    cleanly,    or   with    fissures.      Generally 

THERE    ARE    NO    SOLUTIONS    OF    CONTINUITY. 

Femur. — Lesions  of  the  femur  vary  according  to  the 
part  hit. 

The  line  of  the  growth  cartilage  on  this  bony  extremity 
corresponds  to  the  base  of  the  condyles.  From  this  line  the 
fibres  ascend  vertically,  joining  the  body  of  the  bone  by  the 
most  direct  and  the  shortest  route.  A  bullet  penetrating 
helow  the  line  of  the  cartilage  gives  rise  to  lesions  of  the 
epiphysial  type ;  if  it  penetrates  above  the  line,  it  produces 
lesions  of  the  diaphysial  type. 

On  the  condyles  of  the  femur  the  lesion  consists  of 
contusions,  furrows,  peripheral  perforations,  with  fissures  of  the 
external  shell ;  of  more  central  perforations,  either  clean  or 
with  rare  separation  of  fragments.  These  fragments  show 
different  shapes  ;  they  are  in  juxtaposition  or  in  dissociation. 
Even  in  such  cases  the  lesion  is  usually  simple. 

If  the  bullet  penetrates  at  the  base  of  the  condyles,  it  not  only 
produces  a  perforated  track,  but  it  gives  rise  to  fissures  that 
imperfectly  separate  long  external  or  internal  wedges,  either 
adherent  or  movable  in  antero-posterior  fire,  and  anterior 
and  posterior  wedges,  either  adherent  or  movable  in  transverse 
fire. 

Tibia. — On  the  tibia  the  line  of  the  cartilage  is  only  a  centi- 
metre beneath  the  articular  interspace.  From  this  line  the 
osseous  fibres  descend  directly  towards  the  surfaces  of  the 
bone.  Lesions  without  fissures  are  therefore  shallow,  inter- 
articular  furrows,  more  rarely  perforations.  Most  of  these 
last   are  accompanied   by   fissures   that   limit   external   or 


WOUNDS  OF  THE  LEG  229 

internal  cuneiform  fragments,  whose  points  are  downwards  ; 
they  are  more  or  less  adherent.  This  does  not  complicate 
the  lesion  when  recovery  takes  place  without  suppuration. 

Fibula. — On  the  upper  extremity  of  the  fibula  lesions  are 
simple  (erosions,  grooves^,  perforations).  These  last  are 
more  or  less  comminutive. 

Diag"nosis. — We  must  hardly  expect  to  diagnose  articular 
penetration  by  the  outflowing  of  synovia.  It  is  generally 
absent.  We  have  only  seen  it  once  in  about  ten  penetra- 
tions. On  the  other  hand,  opening  of  the  periarticular 
serous  membranes  gives  rise  to  it.  Hcem arthrosis,  coming 
on  rapidly,  is  abetter  sign  to  go  by.  It  is  common.  But  the 
relationship  of  the  bullet's  track  to  the  different  parts  of  the 
bone  will  often  allow  us  to  establish  a  localized  diagnosis. 

Later  on  pain  along  the  fissures,  or  prominence  of  the 
extremities  of  the  cuneiform  fragments,  and  finally  radiog- 
raphy, will  all  share  in  the  diagnosis. 

Prognosis. — We  have  pointed  out  that  the  thick  adipose 
cushion  which  protects  the  synovial  membrane  often  brings 
about  in  front  of  the  femur  occlusion  of  the  osseous  orifices 
that  the  soft  parts  obturate  at  the  back.  On  the  other  hand, 
the  present  bullets,  very  much  more  than  the  old  ones, 
separate  rather  than  penetrate  the  vertical  fibres  of  the 
capsule  over  the  patella.  The  fibres  of  its  ligamentous 
covering,  being  simply  separated,  stop  up  the  wound  in  the 
bone.  These  are  very  favourable  conditions  for  recovery. 
And  there  are  still  others  :  the  narrowness  of  the  wound ; 
the  rarity  of  the  driving  forward  of  foreign  bodies  derived 
from  the  clothes  when  the  bullet  is  fired  at  point-blank 
range.  With  reference  to  this,  there  is  a  very  different 
prognosis  to  establish  between  wounds  thus  made  and  those 
resulting  from  deflected  bullets  or  from  shell  fragments, 
that  so  often  carry  with  them  very  infective  pieces  of 
clothing. 

Formerly  septic  evolution  carried  off  rapidly  three-quarters 


230  WOUNDS  OF  THE  LOWER  LIMBS 

of  the  soldiers  wounded  in  the  knee.  Diffuse  abscesses 
appearing  very  quickly,  suppurating  arthritis  with  crural 
and  popliteal  fistulae,  were  only  preliminaries  to  septicaemia. 
Femoral  or  tibial  osteomyelitis  completed  the  series  of  the 
sources  of  infection.  Nowadays  a  very  large  majority  of 
these  wounds  recover  without  any  trouble.  From  1 1  per 
cent,  during  the  Russo-Turkish  War,  the  mortality  fell  to 
4*5  in  Cuba.  Not  only  is  recovery  the  rule,  but  it  is 
obtained  nearly  always  without  loss,  or^  at  any  rate,  without 
notable  loss  of  the  movements  of  the  knee.  This  prognosis, 
favourable  both  relatively  and  naturally,  must  not  make  us 
forget  that  great  attention,  the  closest  supervision,  are  abso- 
lutely necessary  in  these  cases,  besides  the  skill  which  is 
requisite  in  their  treatment. 

As  a  principle,  wounded  men  with  penetrating  lesions  of 
the  knee  must  not  be  transported  any  distance,  and  the 
articulation  must  always  be  immobilized  and  covered  over 
with  a  large  dressing.  This,  we  think,  is  not  invariably 
done. 

Treatment. — The  first  dressing  should  insure  disinfection 
of  the  wound  and  of  the  surrounding  parts  (iodine  applica- 
tion) ;  it  should  be  occlusive,  but  not  tight. 

Immobilization  must  be  strict,  brought  about  at  first  by 
the  sound  limb  being  fixed  to  the  wounded  one ;  afterwards 
it  will  be  obtained  by  a  metallic  gutter-shaped  splint,  supported 
above  by  the  thigh,  below  by  the  leg  and  the  foot,  and 
leaving  the  knee-joint  free,  so  as  to  facilitate  supervision  and 
dressing  (gutter  splints  with  valves). 

Very  voluminous  and  very  extensive  h^marthroses  may  be 
drained  through  a  puncture,  or,  if  necessary,  by  an  incision 
made  and  kept  under  strict  aseptic  conditions.  It  is  carried 
out  in  the  external  part  of  the  superior  cul-de-sac  of  the 
synovial  membrane. 

In  cases  of  suppurating  arthritis  (great  oscillations  in  the 
temperature)  the  joint  must  be  incised  laterally,  following  the 


WOUNDS  OF  THE  LEG  231 

internal  and  external  borders  of  the  patella  to  an  extent  of  from 
8  to  10  centimetres.  The  articulation  must  be  thoroughly 
washed  out  with  hydrogen  peroxide,  and  drained  through  a 
transverse  drain  ;  the  dressing  should  not  be  renewed  too 
often.  A  cr^iral  abscess  should  be  opened  by  a  deep  or  supra- 
patellar external  incision  carried  down  almost  to  the  bone,  a 
popliteal  abscess  by  a  median  vertical  incision^  or  by  the  lateral 
incision  of  Marchal  de  Calvi,  under  the  internal  condyle  of 
the  tibia,  and  femoral  abscesses  by  deep  external  incisions. 

Arthrectomy  does  not  seem  to  us  of  much  use,  and  we 
think  that  excision  of  the  semilunar  cartilages  or  scraping 
away  large  portions  of  bone  with  the  idea  of  more  easily 
opening  the  osseous  focus  should  nowadays  not  be  utilized. 

We  pass  over  search  after  foreign  bodies,  which  must  only 
be  carried  out  at  a  late  period  and  with  every  aseptic  pre- 
caution after  exact  indications  had  been  obtained,  unless  it 
is  a  question  of  shrapnel  bullets,  in  which  case  extraction 
should  be  speedy  if  not  immediate. 

Amputation  must  at  first  be  reserved  for  cases  of  gangrene, 
and  afterwards  for  cases  of  very  grave  infective  arthritis 
which  has  not  been  modified  by  arthrotomy.  Excision 
should  only  be  employed  at  a  late  period ;  its  indication  is 
exceptional. 

Wounds  of  the  Thigh. 

The  region  of  the  thigh  extends  from  a  transverse  plane 
three  fingers'  breadths  from  the  superior  border  of  the 
patella  to  a  horizontal  line  which  prolongs  both  in  front  and 
outwards  the  fold  of  the  gluteal  region,  the  ischium. 

Wounds  of  the  thigh  are  very  frequent. 

Wounds  of  the  Soft  Parts. — Bullets  produce  on  the 
thigh  all  the  different  kinds  of  lesions,  even  those  that  take 
up  the  whole  length  of  the  part.  Sometimes  shell  frag- 
ments  give   rise   to    enormous    wounds.      The    interesting 


232  WOUNDS  OF  THE  LOWER  LIMBS 

points  about  these  traumatisms  are  especially  in  the  vasculo- 
nervous  complications. 

The  arteries  in  this  situation  are  both  numerous  and 
large,  hence  haemorrhage  from  them  is  very  grave.  The 
femoral  and  its  principal  branch,  the  profunda ;  muscular 
and  perforating  branches  ;  the  ischiatic  artery  ;  besides  the 
big  veins,  the  femoral,  the  internal  saphenous — all  these 
constitute  the  blood-supply.  In  the  large  cellular  spaces 
of  the  thigh  voluminous  haematomata  develop  rapidly. 

Compression  and  ligature  are  the  treatments  of  haemor- 
rhage, whether  immediate  or  late. 

The  sciatic  nerve,  by  reason  of  its  size,  is  not  divided  by 
bullets,  but  is  indented  or  perforated  when  it  is  not  merely 
contused. 

l^arge  foreign  bodies  often  remain  lodged  in  the  thigh.  In 
these  cases  we  must  remember  those  that  come  from  the 
patient's  pockets.  Direct  incisions  allow  us  easily  to 
extract  foreign  bodies  when  they  have  been  recognized, 
and  this  is  not  so  easy  without  radiography. 

Diffuse  abscesses,  emphysematous  gangrene,  are  not  rare  in 
the  thigh.  They  are  often  caused  by  the  infection  of 
shrapnel  bullets  or  of  shell  fragments.  Therefore  removal 
of  these  projectiles  must  be  carried  out  as  soon  as  possible. 

Osseous  Lesions. — On  the  femur  we  commonly  see  the 
most  typical  diaphysial  lesions  :  Contusions,  fissures,  contact 
fractures,  grooves,  perforations  of  one  side  of  the  bone,  through-and- 
through  perforations,  abrasions. 

Contusions  are  frequent  and  nearly  always  unrecognized. 
The  same  may  be  said  of  fissures,  which  are  generally  very 
long. 

Contact  fractures^  transverse  and  oblique,  direct  or  indirect — - 
that  is  to  say,  at  some  distance  from  the  bony  point  that 
has  been  hit — are  by  no  means  rare.  They  are  especially 
observed  in  the  superior  one-fourth  or  in  the  inferior  one- 
|ifth  of  the  bone. 


WOUNDS  OF  THE  THIGH  233 

In  'Contact  fractures  with  large  splinters  these  last  are  very 
large  (8,  10,  12,  15,  20  centimetres).  They  give  rise  to 
crepitation  which  may  be  called  "  appalling,"  but  it  does 
not  become  multiplied  when  they  are  separated  from  the 
fragments.     The  fractures  heal  without  complications. 

The  comminutive  type  of  contact  fractures  is  also  met  with 
in  the  thigh. 

Grooves  are  often  accompanied  by  oblique  fractures. 

Perforations  of  only  one  side  of  the  bone  are  rare. 

Fracture  by  through-and-through  perforation  is  a  very  com- 
mon osseous  lesion. 

Adherent  splinters  are  from  8  to  12  centimetres  in  length  ; 
free  splinters  are  also  often  of  a  relatively  large  size  (2,  3,  4 
centimetres). 

These  splinters  are  stationary  or  forced  forward. 

On  the  femur,  as  on  the  tibia,  at  short  range,  we  see 
explosive  fractures  with  a  very  large  aperture  of  exit. 

Treatment- — Fractures  of  the  femur  through  bullet 
wounds  were  considered  for  a  long  time  as  necessitating 
amputation  of  the  limb ;  nowadays  they  all  can  be  treated 
by  conservatism,  whatever  their  type,  however  extensive  and  complex 
the  osseous  comminution  and  the  damage  to  the  soft  parts. 

Primitive  immediate  immobilization  is  obtained  at  the 
first-aid  stations,  at  the  ambulance,  hy  fixing  the  sound  limb 
to  the  wounded  one  by  bandages,  or  string,  applied  on  a  level 
with  the  insteps,  and  above  and  below  the  knees. 

Fractures  of  the  femur  must  be  considered  as  a  bar  to  the  patient 
being  transported  any  distance ^  at  least  at  first.  During  the 
transport  the  displacements  become  more  prominent  and 
are  made  worse  ;  the  wounded  man  experiences  pains  that 
are  followed  by  muscular  reaction ;  the  dressings  are  easily 
contaminated  by  the  urine  and  the  faeces.  When  blood 
has  soaked  through  the  dressings  they  are  rapidly  infected. 

As  final  apparatus,  hollowed  oiit  gutter  splints  of  iron  wire 
immobilize  badly.     Being  convex,  they  give  rise  to  ben4- 


234  WOUNDS  OF  THE  LOWER  LIMBS 

ing  of  the  callus  and  render  the  application  of  dressings 
difficult.     They  should  be  rejected. 

Plaster  apparatus  immobilize  well,  but  very  often  they 
make  the  application  of  the  dressings  difficult. 

The  metallic  hollowed  otit  gutter  splints  with  valves  are 
generally  sufficient,  and  render  admirable  service.  When 
extension  is  necessary,  they  effect  it  in  the  following 
manner  :  Counter-extension  is  made  on  the  ischium.  On 
this  bone  rest  the  zinc  lamellae,  which  are  bent  on  them- 
selves and  held  in  place  by  multiple  notches  made  on  the 
upper  edge  of  the  gutter.  Abdominal  bandages,  supported 
at  the  same  time  by  the  bent  and  padded  lamellae  and  by 
an  external  prolongation  of  the  apparatus,  secure  the 
fixity  of  the  counter-extension.  Extension  is  obtained  by 
the  traction  of  the  bandages  on  the  foot.  We  have  never 
treated  fractures  of  the  thigh  by  any  other  apparatus^ 
and  to  its  employment  we  owe  our  great  and  constant 
success. 

We  have  recently  used  our  valvular  glitter  splint  in  a  con- 
tinuous series  of  twenty-five  very  serious  fractures  of  the 
thigh  by  projectiles  ;  most  of  the  cases  had  large  wounds, 
also  rotation  with  angular  deformations  and  shortening, 
which  in  some  reached  8  centimetres.  Application  of  the 
splint  was  at  once  carried  out,  reduction  was  well  kept  up 
with  disappearance  of  the  shortening,  besides,  dressing  was 
easy  whatever  the  seat  of  the  wounds. 

Many  surgeons  use  Tillaux's  or  Hennequin's  extension 
apparatus.  They  establish  a  kind  of  rigid  equation  between 
the  employment  of  these  apparatus  and  our  fractures ;  quite 
wrongly  we  think !  for  these  last  are  often  without  notable 
axial  displacement.  The  apparatus  in  question  would  seem 
to  us  more  worthy  of  recommendation  in  fractures  with 
axial  displacement.  But,  in  our  opinion,  they  are  inferior  to 
the  valvular  gutter  splint  because  they  do  not  allow  the  large 
splinters  to  draiv  together  their  fragments  in  such  a  continuous  and 


WOUNDS  OF  THE  THIGH  235 

SURE  manner,  and  this  is  an  essential  indication  in  the  practice 
of  war  surgery ;  finally,  because  with  them  dressing  is  not 
so  easy. 

It  is  advantageous  to  combine  immobilization  with  a 
complementary  treatment.  In  fractures  of  the  thigh  we  keep 
our  patient  constipated  for  eight  or  ten  days  (mucilaginous 
extract  of  opium,  laudanum),  then  we  open  his  bowels  (oily 
enemata)  only  to  constipate  him  again  for  about  the  same 
time.  After  another  motion  we  may  again  constipate  him 
for  a  third  time. 

During  the  constipation — that  is  to  say,  until  the  fracture 
is  partly  consolidated — we  put  him  almost  exclusively  on 
meat  diet. 

The  constipation  is  well  borne  by  young  healthy  men ;  it 
gives  rise  to  no  elevation  of  temperature,  and  it  has  the 
great  advantage  of  rendering  unnecessary  that  constant 
supervision  which  is  so  tedious  and  difficult  to  procure,  in 
order  to  suppress  all  movement  on  the  part  of  the  patient, 
to  prevent  soiling  of  the  dressings  and  of  the  apparatus ; 
finally,  it  renders  regular  consolidation  far  easier. 

In  fractures  of  the  upper  third  it  may  be  necessary  to 
exercise  traction  in  abdttction,  but  we  think  this  position 
ought  not  to  be  kept  up. 

Certain  complicated  apparatus  employed  in  ordinary 
practice  seem  to  us  to  be  of  very  little  use,  and  the  diuretic 
sanguinary  method  is  especially  to  he  avoided.  It  complicates 
the  traumatism,  and  the  points  have  some  difficulty  in 
penetrating  and  supporting  the  movable  splinters. 

We  should  strive  to  perfect  the  final  results  by  using,  at 
the  right  moment,  passive  movements  of  the  foot  and  the 
knee ;  this  is  easily  done  with  the  valvular  gutter  splint ; 
we  avoid  in  this  way  any  deformed  callus  produced  by 
rotation  of  the  foot  and  bad  coaptation  of  the  fragments 
and  of  the  splinters.  Pseudarthroses  will  to  a  large  extent 
be  prevented  if  we  refuse  to  perform  any  operation  for  the 


236  WOUNDS  OF  THE  LOWER  LIMBS 

removal  of  splinters  and  if  we  do  not  carry  extension  too 
far,  especially  in  very  comminuted  foci. 

A  cured  fvactuve^  with,  slight  or  average  shortening  of  the  limb, 
which,  however,  is  in  good  axial  position,  is  an  honour  to  the 
surgeon  who  treated  the  patient. 

When  there  is  abundant  suppuration  of  the  focus,  we 
must  hasten  to  remove  the  free  splinters  which  had  been 
allowed  to  remain  at  first.  Let  us  point  out  that  these  will 
he  found  in  the  neighbourhood  of  the  aperture  of  exit. 

Wounds  of  the  Hip. 

The  hip  comprises  the  inguino-crural  region  in  front,  the 
gluteal  region  at  the  back,  and  deeply  the  coxo-femoral 
articulation.  ,        , 

Articular  lesions  of  the  hip  are  3-8  per  cent,  of  joint 
wounds. 

Wounds  of  the  Soft  Parts. — In  this  fleshy  region  the 
setons  are  extensive,  the  culs-de-sac  sometimes  complicated 
by  bulky  foreign  bodies.  Large  fragments  of  hollow  projec- 
tiles give  rise,  on  the  buttocks  and  in  the  groin,  to  very 
large,  ragged  wounds.  We  have  seen  some  that  included 
the  whole  of  one  buttock. 

Hcemorrhage  from  the  groin  is  especially  serious.  Both  the 
femoral  artery  and  vein  are  of  easy  access,  their  relations 
being  so  well  marked.  Their  direct  ligature  is  the  surgical 
treatment  of  choice  in  haemorrhage  due  to  their  lateral  or 
central  perforation,  whilst  direct  compression  is  the  primary 
preparatory  treatment.  This  last  would  be  final  in  some 
surgeons'  hands. 

Wounds  of  the  arteries  in  the  gluteal  region  are  formid- 
able. We  have  seen  some  of  these  cases.  The  big  classical 
incision  for  the  gluteal  artery  would  allow  us  to  verify  a 
difficult  differential  diagnosis,  and  to  guarantee  the  applica- 
tion  of   the   proper   surgical   treatment.     Immediate   com- 


WOUNDS  OF  THE  HIP  237 

pression  after  freeing  the  external  wound  would  only  be  a 
makeshift.  Tamponment  and  pressure  must  not  be  main- 
tained for  long,  owing  to  their  rendering  the  parts  liable  to 
diffuse  putrid  inflammation. 

We  have  nothing  special  to  say  with  reference  to 
hsematomata  and  to  femoral  or  gluteal  aneurysm,  or  about 
wounds  of  the  sciatic  nerve. 

Osseous  Lesions.— Openings  in  the  capsule  without 
osseous  lesion  are  exceptional.  They  are  impossible  to 
diagnose. 

Femur. — The  line  of  the  growth,  cartilage  of  the  femoral 
head  is  lost  in  the  anatomical  neck. 

Another  line  of  cartilage,  oblique  below  and  externally,  passes 
at  the  base  of  the  great  trochanter  and  separates  this  base  from 
the  remainder  of  the  bone. 

The  lesser  trochanter  is,  from  the  point  of  view  of  its 
constitution,  a  part  superadded  to  the  remainder  of  the 
femur. 

The  limits  of  the  surgical  neck  are — Above,  the  anatomical 
neck ;  below,  the  intertrochanteric  line.  Its  fibres  that 
follow  the  fissural  tract  are  divided  into  two  fasciculi :  one, 
the  internal,  large  above,  goes  from  the  head  of  the  femur 
to  the  lesser  trochanter  that  it  encircles  ;  the  other,  the 
external,  has  a  base  corresponding  to  the  head  of  the  femur, 
and  its  fibres,  some  horizontal  above,  others  oblique  below, 
reach  the  base  of  the  great  trochanter  and  are  prolonged 
under  it. 

1.  The  HEAD  OF  THE  FEMUR  may  be  eroded,  hollowed  out  as 
with  a  gouge,  perforated.  These  lesions  are  commonly  simple, 
and  the  anatomical  neck  raises  a  bar  to  the  extension  of 
fissures.  The  cotyloid  cavity,  its  pad,  the  round  ligament, 
and  the  capsule,  retain  the  free  fragments. 

2.  Bullets  that  penetrate  on  the  level  of  the  anatomical 
NECK  hollow  it  out  as  with  a  gouge,  perforate  it,  and  in  the  last 
case  may  separate  the  head  either  incompletely  or  com- 


238  WOUNDS  OF  THE  LOWER  LIMBS 

pletely    by   a   subperiosteal   fissure.     There  is  no  primitive 
separation. 

3.  On  the  SURGICAL  neck  bullets  may  leave  simple 
indentations,  or  give  rise  to  perforations,  which  are  either 
simple  or  radiated  by  fissural  tracts.  The  most  remarkable 
of  these  perforations  with  fissures  is  the  one  in  which  what 
may  be  called  the  femoral  spur  is  separated.  This  spttv  is 
represented  by  a  bony  wedge  that  includes  the  head  of  the 
femur,  the  internal  half  or  third  of  the  surgical  neck,  and  the 
lesser  trochanter  (Delorme). 

4.  Above  the  intertrochanteric  line  the  lesions  are  of  the 
diaphysial  type.  The  fissures  are  those  of  large  diaphysial 
splinters. 

Fractures,  with  solution  of  continuity  of  the  surgical 
neck,  are  very  much  more  uncommon  than  those  with  no 
solution  of  continuity. 

5.  The  great  trochanter  may  be  eroded,  furrowed,  per- 
forated; THE  lesser  trochanter  may  be  hollowed  out  as  with 
a  gouge,  abrased.     These  lesions  are  limited. 

6.  The  cotyloid  brim  may  be  eroded,  furrowed.  Again, 
the  lesion  is  limited  and  simple. 

7.  When  there  is  penetration  from  without  inwards  of  both 
the  great  trochanter  and  the  surgical  neck,  there  is  a 
tendency  to  separation  of  the  femoral  extremity  into  one 
or  two  incomplete  lateral  wedges,  with  a  diaphysial  inferior 
point ;  these  wedges  are  always  adherent. 

Diagnosis. — Diagnosis  of  osseous  lesions  of  the  hip 
cannot  be  made  by  searching  only  for  abnormal  mobility, 
faulty  position  of  the  limb,  shortening,  outflow  of  synovia, 
or  swelling  of  the  region.  These  signs  are  often  absent. 
Localized  pain  brought  about  by  pressure  is  an  excellent 
presumptive  sign.  It  would  be  blamable  to  endeavour  to 
find  abnormal  mobility  or  crepitation.  The  relationship  of 
the  wound  to  the  region  occupied  by  the  articulation  will 
specially  serve  as  guide,  and,  with  the  indications  we  have 
given,  will  render  the  diagnosis  easy. 


WOUNDS  OF  THE  HIP  239 

i..(<2)  If  we  divide  into  three  equal  parts  the  Fallopian 
line  (Poupart's  ligament),  which  extends  from  the  anterior 
superior  iliac  spine  to  the  spine  of  the  pubes,  the  middle 
segment  gives  from  above  the  limits  of  the  articulation. 

2.  Below  the  limits  are  fixed  by  the  great  and  lesser 
trochanters.  The  superior  border  of  the  great  trochanter 
is  easily  found.  The  lesser  trochanter  corresponds  to  the 
centre  of  the  anterior  surface  of  the  thigh  on  a  horizontal 
line  that,  prolonged  outwards,  would  reach  the  ischium, 
which  is  easily  felt,  or,  if  preferred,  on  the  line  that,  pro- 
longed outwards,  would  reach  the  inner  part  of  the  gluteal 
fold. 

3.  Now  let  us  unite  by  two  curves,  the  superior  one 
concave  above,  the  inferior  concave  below,  the  two  points 
limiting  the  middle  segment  of  the  Fallopian  line  (Pou- 
part's ligament)  to  the  great  trochanter  on  one  side,  to  the 
lesser  trochanter  on  the  other,  and  we  shall  then  have 
marked  out  the  area  of  .the  head,  the  anatomical  neck,  and 
the  surgical  neck  of  the  femur  in  front. 

{h)  At  the  back  we  get  the  same  result  in  the  following 
way:  i.  We  trace  a  line  that  joins  the  ischium  to  the  most 
prominent  and  the  most  external  point  of  the  iliac  crest. 

2.  We  ascertain  exactly  the  site  of  the  lesser  trochanter. 
It  corresponds  to  the  middle  part  of  the  posterior  surface  of 
the  thigh  on  the  horizontal  line  that  starts  at  the  ischium. 

3.  We  then  seek  for  the  prominent  border  of  the  great 
trochanter. 

4.  If,  at  a  finger  s  breadth  above  the  superior  border  of  the 
great  trochanter,  we  draw  a  horizontal  line,  at  the  point  of 
meeting  of  this  line  with  the  oblique  ilio-ischiatic  one 
already  drawn,  there  we  shall  find  the  upper  limit  of  the  head 
of  the  hone.  The  lower  limit  of  the  head  corresponds  to 
the  meeting  of  a  horizontal  line  carried  a  finger's  breadth 
below  the  level  of  the  great  trochanter's  superior  border 
to  the  oblique  ilio-ischiatic  line. 


240  WOUNDS  OF  THE  LOWER  LIMBS 

The  points  that  limit  the  head  of  the  femur  thus  indicated 
are  afterwards  united  by  curved  lines  to  the  great  and  lesser 
trochanter. 

Thus  we=  find  out  with  sufficient  accuracy  the  posterior 
area  of  the  head,  of  the  anatomical  and  of  the  surgical  neck. 
The  line  between  the  trochanters  separates  that  which  is  in 
relation  to  the  epiphysis  above  and  to  the  diaphysis  below. 

Later  on,  radiography  will  furnish  very  important  infor- 
mation in  the  diagnosis,  especially  in  cases  of  epiphysial- 
diaphysial  lesions. 

Prognosis. — Formerly,  prognosis  of  bullet  wounds  of 
the  hip,  with  osseous  lesions,  was  extremely  severe.  In 
the  War  of  Secession  the  mortality  was  847  per  cent.;  in 
the  Franco- German  War,  79-7  per  cent.  In  the  Cuban 
War  it  was  33  per  cent.,  and  in  the  Transvaal  28*6  per 
cent. 

It  was  the  suppurating  arthritis  of  the  joint  that  brought 
about  the  death  of  the  wounded  men  ;  and  in  those  unfor- 
tunately too  rare  cases  that  recovered  an  ankylosed  articu- 
lation was  left.  Nowadays  cure  is  frequent,  and  very  often 
the  mobility  of  the  joint  is  preserved. 

Yet  infectious  complications  are  still  observed,  such  as 
large  haematomata  or  foreign  bodies,  whose  appearance 
is  stimulated  by  the  neighbourhood  of  the  rectum  and 
bladder. 

The  prognosis  of  wounds  of  the  hip  by  firearms  is 
influenced  by  that  of  the  complications,  and  especially  by 
grave  haemorrhage. 

Certain  conditions,  in  our  opinion,  seem  to  mitigate  the 
prognosis ;  for  example,  wounding  of  the  joint  by  a  bullet 
fired  point-blank  from  a  great  distance,  which  gives  rise  to 
very  small  lesions  ;  or  absence  of  a  posterior  wound,  which 
is  so  easily  infected.  In  posterior  osseous  lesions  the  neck 
of  the  femur  is  to  a  large  extent  untouched  ;  communicated 
infection  is  much  easier  when  the  track  is  widely  open.     In 


WOUNDS  OF  THE  HIP  241 

the  anterior  cul-de-sac  wounds  the  thick  capsule,  the  fibres 
of  which  have  been  separated,  is  in  a  certain  measure  an 
obstacle  to  infection. 

Treatment. — Men  with  fractured  hip  should  never  he  trans- 
ported to  any  distance.  Immediate  immobilization  is  obtained 
by  bringing  together  the  two  lower  limbs.  This  method  of 
temporary  immobilization  can  still  be  of  use  as  an  ultimate 
measure  when  there  is  no  osseous  solution  of  continuity. 

To  immobilize  the  hip,  various  means  have  been  pro- 
posed :  decubitus  on  a  well-padded  plank,  in  Bonnet's 
gutter  apparatus  ;  the  employment  of  Smith's  splint,  which 
takes  its  point  of  support  from  the  whole  of  the  anterior 
surface  of  the  limb  ;  the  external  splints  of  Desault  and 
Isnard  ;  large  plaster  apparatus  ;  and,  finally,  various  exten- 
sion apparatus.  We  do  not  believe  that  the  first-mentioned 
apparatus  are  necessary.  There  is  no  assimilation  possible 
between  lesions  by  firearms  and  ordinary  fractures  ;  and, 
on  the  other  hand,  extension  creates  the  danger  of  separation  of 
the  fragments.  As  a  general  rule,  we  think  that  bringing 
together  the  lower  limbs  is  sufficient. 

In  order  to  avoid  any  displacement  of  the  fragments 
occurring,  and  also  the  pain  which  always  accompanies  the 
movements  rendered  necessary  for  alvine  discharges,  we 
constipate  these  patients  as  we  do  those  with  a  fractured 
thigh. 

The  dressings  must  be  large,  going  very  much  beyond 
the  limits  of  the  region ;  at  the  very  least  they  should  reach 
as  far  as  the  groove  between  the  nates,  and,  above  all,  they 
should  remain  fixed  in  place.  Now,  what  dressings  realize 
these  conditions  at  the  present  time  ?  To  obtain  them  it  is 
necessary  for  a  large  compress  —  applied  in  the  manner 
recommended  by  Mayor,  taking  its  point  of  support  from 
circular  abdominal  bandages  or  from  a  body  bandage,  and 
below  from  circular  crural  bandages,  and  then  consolidated 
by  a  spica — entirely  to  cover  a  large   mattress   made  of 

16 


242  WOUNDS  OF  THE  LOWER  LIMBS 

aseptic  material.  But  we  still  ask  for  more,  and  we  advise 
all  surgeons  to  follow  our  practice,  which  consists  in 
covering  all  the  regions :  inferior  abdominal,  crural,  gluteal 
and  perinaeal.  The  constipation  of  the  patient  allows  us  to 
do  this ;  besides,  it  simplifies  to  a  large  extent  the  nursing. 

Immediate  extraction  of  free  splinters  is  not  necessary, 
but,  in  an  infected  focus,  it  may  be  obligatory,  and  still 
more,  at  the  time  of  removal,  we  may  find  ourselves,  in 
these  cases,  compelled  to  take  away,  with  the  splinters, 
osseous  fragments  of  the  head  of  the  bone  and  even  part  of 
the  surgical  neck  (spur).  We  must,  however,  be  sparing 
with  these  operations,  and  only  perform  them  in  good 
earnest  when  driven  by  necessity.  A  fortiori  we  must  not 
endeavour  to  do  a  typical  resection. 

The  anterior  incision  of  Hueter  outside  the  femoral  vessels 
brings  us  well  and  directly  down  on  the  joint,  on  the  head, 
and  on  the  neck  of  the  femur.  At  the  back,  an  incision 
following  the  direction  of  the  fibres  of  the  gluteus  maximus 
allows  us  to  bring  into  view  the  head^  the  neck,  and  the 
great  trochanter,  and,  if  necessary,  the  acetabulum.  The 
difficulty  does  not  lie  so  much  in  the  exposure  of  the  joint 
as  in  the  removal  of  splinters  that  are  partly  adherent.  We 
should  proceed  by  successive  freeing. 

In  no  case  should  we  resect  under  the  line  between  the  trochanters. 
The  result  is  deplorable. 

Abscesses  are  reached  in  front  by  the  incision  for  ligature 
of  the  femoral,  at  the  back  by  the  gluteal  incision. 

Primitive  disarticulation  of  the  hip-joint  is  contra- 
indicated  in  bullet  lesions  with  no  complications.  It  may 
become  necessary  owing  to  gangrene  or  to  nearly  total 
abrasions  produced  by  large  shell  fragments  with  laceration 
of  the  vessels  and  of  the  nerves,  or  subsequently  owing  to 
femoral  osteomyelitis.  The  anterior  racket  operation  with 
preliminary  ligature  of  the  artery  is  the  procedure  of  choice. 


INDEX 


Abdomen,  regions  of,  i6S 

Abdomen,  wounds  of,  167  ;  non- 
penetrating and  penetrating, 
169  ;  diagnosis,  173  ;  course  and 
prognosis,  174;  treatment,  176 

Abrasions,  104,  146;  partial,  54; 
total,  55,  57,  207,  232 

Abscess,  cerebral,  139  ;  perirectal, 
188 

Acromion,  159 

Action,  divulsive  and  propulsive, 
10 

Active  power,  7,  22 

Adrenalin,  53 

Alcohol,  165 

Alum,  53 

American  Civil  War,  43,  102, 118, 
142,  175,  177,  240 

Amputation,  102,  no,  122,  126, 
215,  221,  226,  231 

Anaemia,  acute,  46,  47 

Anatomical  neck  (femur),  237 

Aneurysmal  varix,  51 

Aneurysms  :  traumatic,  49  ;  arte- 
rial, 49 

Ankylosis,  209 

Anodynes,  164 

Antipyrin,  53 

Antitetanic  serotherapy,  116 

Anuria,  182 

Anus,  escape  of  blood  through, 

173 
Aperture:    entry,    24,    104,    in; 

exit,  25,  104,  III 
Apparatus,  96 
Apparent  death,  48 
Arm,  wounds  of,  210 
Arteries,  wounds  of,  36 ;  prognosis, 

40 
Arterio-venous  aneurysms,  50 
Arthrectomy,  231 
Arthritis,  no 


Articulations :  lesions  of,  103  ; 
types,  106;  diagnosis,  107  ;  prog- 
nosis, 108 ;  treatment,  109 

Assaky,  59 

Astragalus,  221 

Austrian  bullets,  3,  4,  170 

Autograft,  60 

Autoplasty,  145 

Auvray,  139,  140 

Bacillus,  Vincent's,  116 

Balkan  War,  i,  36,  39,  41,  43,  92, 
loi,  164,  177,  193,  195 

Ballistic  data,  5  ;  shells,  20 

Bartels,  186 

Bascule  movements,  6 

Bayonets,  i 

Belgian  bullets,  3,  4 

Billet,  H.,  33,  139,  140 

Bladder,  wounds  of,  185 ;  diag- 
nosis and  prognosis,  185  ;  treat- 
ment, 186  ;  puncture  of,  188 

Boeckel,  E.,  line  of,  198 

Bonnet's  splint,  194 

Bornhaupt,  44,  50 

Brachial  artery,  206 

Brain,  wounds  of,  128  ;  diagnosis, 
132;  evolution,  135  ;  prognosis, 
135;  treatment,  136 ;  complica- 
tions, 138 

Brentano,  45 

Buccal  floor,  wounds  of,  151 

Bullets,  2,  3,  4,  5,  61,  62,  63,  64, 
65,  66 ;  modus  operandi  of,  9  ; 
humanitarian,  12  ;  explosive  or 
dum-dum,  14 ;  from  shells,  28, 66, 
92  ;  change  of  shape,  65,  88,  175 

Bursting  height,  2 1 

Caffeine,  165 
Callus,  painful,  107 
Camphorated  oil,  165 


243 


2^4 


WAR  SURGERY 


Carbolic  acid,  34,  35,  100 

Carotid  arteries,  wounds  of,  153 

Carrel,  46' 

Carriere,  34 

Cartilage,  growing,  104,  206 

Case-shot,  19 

Catheterism,  186,  188 

Cerebral  shock,  134 

Cerebro-medullary  shock,  195 

Cerebro-spinal  fluid,  escape  of,  192 

Champenois,  98,  210 

Chauvel,  36 

Chavasse,  176 

Cheeks,  wounds  of,  151 

Chenu,  48 

Chest,  wounds  of,  158 ;  non- 
penetrating, 158  ;  penetrating, 
161  ;  zones  of,  162,  prognosis, 
166 

Cheyne-Stokes  respiration,  192 

Chloride  of  calcium,  53 

Chloroform,  115 

Circular    ligation  of    the    limbs, 

165 

Clavicle,  158 

Clothing :  fragments  of,  66  ;  exam- 
ination of,  67 

Cold  steel,  i,  2,  71,  128,  i6g 

Comminution,  87 

Complications,  general,  113 

Compression,  47  ;  digital,  41  ;  in- 
direct, 53  ;  mechanical,  41  ; 
distal,  47  ;  direct,  5^  ;  cerebral, 
134  ;  cord,  191,  225,  227,  232 

Conservatism,  94 

Constipation,  235 

Contusions,  23,  36,  43,  46,  54,  71, 
104,  III,  112,  123,  128,  129, 
132,  134,  146,  149,  153,  154,  158, 
160,  169,  181,  185,  191,  204,  210, 
224,  232 

Coracoid  process,  159 

Cornea,  lesions  of,  147 

Courtot,  34 

Cracks,  72,  128,  129,  132,  204 

Crimea,  115,  175 

Crushing,  112,  123 

Cuban  War,  64,  240 

Cul-de-sac  wounds,  151,  161,  169, 
171,  181,  185 

Cuneo,  60 

Cystotomy,  suprapubic,  187 


De  Calvi,  Marchal,  23I 

Deflection  movements,  6 

De  Giry,  Chasteney,  139 

Delirium,  nervous,  113 

Deljalitzky,  138 

Delorme,  36,66,  97,  129,  142,  159, 
176,  178,  199,  219 

De  Moy's  splint,  97 

Dent,  193 

Depressions,  128,  129,  132 

Diaphyses,  bony  lesions  of,  71  ; 
diagnosis,  84 ;  prognosis,  etc., 
89 ;  complications,  91  ;  treat- 
ment, 94  ;  resection  of,  102 

Diet,  148 

Dieulafoy,  122 

Disarticulation,  216,  242 

Division,  complete,  39 

Drain,  regrettable,  100 

Dressing,  33 

Dressing-packet,  31 

Dorsalis  pedis  artery,  219 

Dyspnoea,  162 

Ear,  lesions  of,  147 

Elbow,  wounds  of,  206  ;  diagnosis, 

treatment,  208 
Emphysema,  155,  162,  165 
English  bullets,  3,  4 
Epilepsy,   traumatic    and    Jack- 

sonian,  143 
Epiphysis,  104,  198 
Ergotine,  53 
Erosions,  23,  104 
Erysipelas,  surgical,  118 
Ether,  165 

Excision,  atypical,  216 
Excoriations,  181,  185,  217 
Extension,  forced,  41 
Extirpation  (aneuryms),  52 
Eye,  wounds  of,  145 

Face,  wounds  of,  145 

Faecal  matter,  escape  of,  187 

Femoral  artery,  232 

Femur,  228,  233,  237 

Ferraton,  19,  39, 118,  119, 135, 152, 

155,  156,  170,  179,  200,  205,  209, 

217 
Fessler,  36 
Fibula,  223,  229 


INDEX 


HS 


Fingers,  wounds  of,  197  ;  com- 
pHcations,  198  ;  treatment,  199 

Firearms,  2 

First  Empire  wars,  115 

Fissures,  72  ;  symmetrical,  oppo- 
site, 73;  concentric,  iii,  128, 
T29,  131,  132,  158,  161,  198,  204, 
210,  224,  232 

Flat  bones,  lesions  of,  iii 

Flexion,  forced,  41 

Focus,  the  osseous,  83  ;  anti- 
sepsis of,  100 

Foot,  wounds  of,  diagnosis,  com- 
plications, 218 ;  treatment,  220 

Foratini,  59 

Forearm,  wounds  of,  204 ;  treat- 
ment, 205  ;  prognosis,  206 

Foreign  bodies,  92,  loi,  124,  148 
(ear),  160,  174,  186,  199,  232 

Foreign  bodies  (clothes),  35,  61, 
66 ;  diagnosis,  68,  89 ;  treat- 
ment,  69 ;  cerebral,  141 

Fourmies,  65 

Fowler's  position,  178,  179 

Fractures,  contact,  73,  86,  149, 
158,  198,  204,  210,  223,  224, 
232 ;  with  large  splinters,  86, 
149,  158,  198  ;  and  transverse 
and  oblique,  74 ;  by  perfora- 
tions, 86  ;  by  groove,  87 ;  con- 
secutive care  of,  loi  ;  of  inner 
table,  129 ;  tangential,  149 ; 
clean,  207 

Fragments,  40 

Franco-Prussian  War,  50,  240 

French  bullets,  3,  4 

Freyer,  54,  58 

Furrows,  23,  104,  iii,  112,  129, 
151,  161,  171,  191,  203,  207 

Fuse,  percussion  and  time,  17,  21 

Gangrene,  92,  114  ;  traumatic,  92 ; 

hospital,  116  ;  emphysematous, 

119,  232 
Gargling,  148 
Gelatine,  53 

Genital  organs,  wounds  of,  188 
German  bullets,  3,  4 
German  wars,  102 
Glenoid  cavity,  214 
Glycerine,  carbolized,  147 
Grazings,  128 


Grenades,  19 

Grooves,  80,  89, 104,  iii,  128,  129, 

158,  160,  171,  191,  198^  203,  204, 

207,  224,  232 
Gross,  114 
Guerin,  A.,  94,  119 
Guns,  16 

Haemarthrosis,  229 

Hsematemesis,  173 

Hsematomata,  152,  153,  155,  227 

Haematuria,  182,  185 

Haemoptysis,  162 

Haemorrhage,  48,  151,  153,  155, 
156,  160,  172,  173,  183,  189,  192, 
198,  219,  224,  227,  236 ;  late 
and  secondary,  52  ;  primary,  91 

Haemothorax,  165 

Haga,  176 

Hands,  wounds  of,  197 ;  com- 
plications, 198  ;  treatment,  199 

Harris,  179 

Hashimoto,  Dr.,  59 

Hearing,  diminution   or  loss  of, 

147 
Heart,  wounds  of,  166 
Hennequin,  98,  210,  234 
Hernia  of  the  brain,  140 
Hernia  of  the  lung,  163 
Hildebrandt,  40,  50 
Hip,  wounds  of,   236  ;  diagnosis, 

238  ;  prognosis,  240 ;  treatment, 

241 
Hispano-American  War,  156 
Holbeck,  115,  142 
Horsley,  139 
Hot  water,  53 
Howitzer  shells,  17 
Hueter,  242 

Humanitarian  bullets,  12 
Humerus,  207,  213 
Hydrogen  peroxide,  35,  90,   100, 

121,  148,  200 

Immobilization,  94,  no,  150,  159, 
160,  162,  176,  210,  225,  233, 
241 

Incision,  buttonhole  median  perin- 
seal,  187  ;  lateral,  211  ;  external, 
212;  shoulder -joint,  216 

Indentations,  43,  iii,  154 

Infection,  perirectal,  187 


246 


WAR  SURGERY 


Instep,  wounds  of,  221  ;  diagnosis, 
treatment,  222 

Intestine,  lesions  of,  169 

Intrarhachidian  abscess,  193 

Iodine,  33,  34,  35 

Iodoform  gauze,  100,  148  ;  oint- 
ment, 146 

Iris,  lesions  of,  147 

Irrigations,  148 

Italian-Turkish  War,  177 

Jaundice,  173 
Journee,  9 

Karbine,  89,  138 

Kidneys,  wounds  of,   181  ;  pelvis 

of,  182  ;  treatment,  182 
Kirmisson,  48 
Knee,  wounds  of,  226  ;  diagnosis, 

prognosis,  229;  treatment,  230 
Kuttner,  40 

Laminectomy,  193 

Lance,  2 

Laparotomy,  177,  179,  187 

Larrey,  96,  186 

Larynx,  154 

Lasegne,  142 

Laurent,  Professor,  49,  50,  59,  60, 

158,  162,  166,  191,  193,  195,  196 
Ledran,  216 
Leg,  wounds  of,  223  ;   diagnosis, 

treatment,  224 
Legal  position  of  soldiers  wounded 

in  the  skull  and  brain,  143 
Lidell,  43 
Ligature,  44,  45,  47 ;  at  a  distance, 

52  ;  in  the  sac,  52,  232 
Lips,  wounds  of,  151 
Liver,  171 
Loison,  43 

Lower  limbs,  wounds  of,  217 
Lucas-Championniere,  125 
Lumbar  region,  wounds  of,  181 ; 

treatment,  182  ;  incision,  183 
Lungs,  wounds  of,  161 ;  diagnosis, 

162  ;    complications  and  treat- 
ment, 163 

MacCormac,  177 

Makins,  42,  186 

Manchurian  Campaign,  34,  43,  44, 
45.  50,  92,  loi,  118,  138,  177 


i   Manteuffel,  44 

Matthew,  37 

Maxilla,  inferior,  wounds  of,  149 

Maxillae,  upper,  wounds  of,  148 

Mayor's  cravat  bandage,  41  ;  ap- 
paratus, 97,  221,  241 

MeduUo-rhachidean  lesions,  diag- 
nosis, 192  ;  prognosis  and  treat- 
ment, 193 

Meningo-encephalitis,  138 

Meningo -medullary  lesions,  191 

Mercury,  bichloride,  34 

Meslier,  139 

Metacarpals,  198 

Mignon,  139 

Mineral  waters,  102 

Mitrailleuse,  5 

Morel's  garrot,  41 

Morocco  Campaign,  51,  177 

Movement,  passive,  no 

Murphy's  incision,  179,  187 

Musculo-spiral  nerve,  210 

Mutilation,  self-,  200 

Nancy,  179,  180 

Nape  of  the  neck,  wounds  of,  152 

Neck,  wounds  of,  152  ;  antero- 
lateral regions,  153  ;  diagnosis, 
154;  prognosis,  155;  treatment, 
156 

Nephrotomy,  183 

Nerves,  wounds  of,  54,  (neck), 
154 ;  signs  of,  55 ;  diagnosis, 
treatment,  56 

Neuritis,  60 

Neuromata,  59 

Neurotomy,  60 

Neurotripsy,  60 

Normal  saline,  48 

Nose,  wounds  of,  145 

Notches,  159,  160 

Nusbaum,  49 

OEsophagus,  154 

Oliguria,  182 

Ophthalmia,  sympathetic,  146 

Orbit,  wounds  of,  145 

Oscillation  movements,  6 

Osteomyelitis,  93 

Otis,  43,  191,  192 

Pain,  113 


INDEX 


247 


Palmar  incisions,  129 

Pancreas,  172 

Pare,  96 

Patella,  228 

Pauzat,  217 

Pellerin,  34 

Pelvic  bones,  lesions  of,  184 

Pelvis,  vi^ounds  in  the  region  of, 
184 

Penetrating  wounds,  103,  104, 
161 

Penetration,  8 

Penis,  189 

Perforation,  77,  88,  112;  complete, 
38,  III ;  lateral,  43  ;  central, 
43;  total,  46,  54,  57,  78,  104, 
151  ;  incomplete,  77,  104,  iii ; 
through  -  and  -  through,  128  ; 
single  and  double,  129,  130,  135  ; 
tangential,  131  ;  frontal,  pari- 
etal, temporal,  occipital,  ver- 
tical, 134,  146  ;  (eye),  153,  154, 
159,  160,  161,  169, 171,  181, 185, 
191,  198,  203,  204,  207,  224,  232 

Peri-articular  wounds,  226 

Peritonitis,  172,  174 

Phalanges,  198 

Pharynx,  154 

Pirogoff,  43  ;  pouch  of,  25 

Plantar  arteries,  219 

Plaster  apparatus,  97 

Pleurisy,  163,  165 

Pneumothorax,  162 

Poirier,  139 

Ponce  t,  114 

Popliteal  vessels,  226  ;  nerves, 
227 

Potassium  permanganate,  148 

Pravaz  syringe,  48,  122,  165 

Preterre,  151 

Profunda  artery,  232 

Projectiles,  2 ;  secondary,  9,  10 ; 
pointed,  10 ;  lesions  caused  by, 
71 ;  large,  123,  131  ;  wind  of, 
123 

Prostate,  wounds  of,  188 

Prosthesis,  145 

Pseudo-arthroses,  loi 

Pyaemia,  118,  iig 

Pyonephrosis,  183 

Quinine,  53 


Radiography,  73,  87,  108,  141,  146, 

160,  208,  215 
Radius,  206,  207 
Range,  7 
Raoult-Deslonchamp's  apparatus, 

98,  222,  225 
Reclus,  124 

Rectum,  wounds  of,  184,  187 
Reduction  of  fracture,  99 
Reeb,  114 
Resection  :    atypical,    no,    209  ; 

typical,  242 
Retzius,  cavity  of,  185 
Reverdin,  67 

Revolver  shots  wounds,  28 
Ribs  and  cartilages,  160 
Ricochets,  8 
Robert,  34 

Rohmer,  Professor,  179 
Rouvillois,  51 
Rupture  (eye),  146 
Russian  bullets,  3,  4,  170 
Russo-Japanese  War,  34,  41,  115, 

175.  177 
Russo-Turkish     Campaign,    118 

230 

Sabre,  2 

Sac,  incision  of,  52 

Saigo,  50 

St.  Petersburg,  riot  in,  65 

St.  Quentin,  114 

Sarrazin's  apparatus,  97 

Scalp,  wounds  oi.  128 

Scapula,  159 

Sciatic,  lesions  of,  184 

Sclerotic,  lesions  of,  147 

Scrotum,  188 

Sections,  46 

Septicaemic  fever,  119 

Serum  :  antidiphtheritic,  53  ; 
horse,  53 

Setons,  24,  151 

Shells:  Field  Artillery,  16;  mit- 
raille,  17,  20  ;  systematic  burst- 
ing, 17;  explosive,  18,  20,  22; 
mixed  universal,  19  ;  bursting 
of,  40  ;  armour-piercing,  124 

Short  bones,  lesions  of,  in,  112 

Shoulder,  wounds  of,  212  ;  diag- 
nosis, 214;  treatment,  215 

Shrapnel,  17,  18 


248 


WAR  SURGERY 


Skull,  wounds  of,  128  ;  diagnosis, 
132;  evolution,  135  ;  prognosis, 
135;  treatment,  136  ;  complica- 
tions, 138  ' 

Soft  parts,  wounds  of,  23,  28 

Souffle,  49 

Souligoux,  179 

Sphincter  ani,  dilatation  of,  187 

Spinal  cord,  wounds  of,  190 

Spine  of  scapula,  159 

Spleen,  171 

Splinters,  shell,  28,92  ;  small,  40  ; 
free,  81 ,  100  ;  adherent,  82 

Stenon's  duct,  151 

Sternum,  160 

Stomach,  171 

Strasburg,  114 

Stupor,  local  and  general,  114 

Subclavian  arteries,  wounds  of, 
153 

Sulphuric  ether,  injections  of,  48 

Suppuration,  42,  90,  93,  100,  117, 
160 

Surgical  neck  (femur),  237 

Suture  of  arteries,  45  ;  in  aneur- 
ysms, 52  ;  of  nerves,  59 

Sword,  2 

Syme,  221 

Symptomatology,  40 

Symptoms,  consecutive  (skull, 
brain),  141 

Syncope,  48 

Takuoka,  Dr.,  59 

Tarsus,  218 

Tearing  away  of  tissues,  123,  169 

Testicle,  189 

Tetanus,  115,  220 

Thigh,  wounds  of,  231;  treatment, 

233 
Thoraco-abdominal  wounds,  165 
Thrace  Campaign,  118 
Thyroid,  154 
Tibia,  224,  228 
Tillaux,  234 
Tissues,  elastic,  10 
Toes,  218 
Tongue,  wounds  of,  151 


Trachea,  154 

Tracheotomy,  157 

Track,  25,  104 

Trajectory,  7 

Transfusion,  48 

Transporting  wounded,  41 

Transvaal  War,  41,  43,  74,  115, 

175,  176,  177.  186,  193,  240 
Traumatopnoea,  162 
Treatment,  31,  41,  49 
Trifaiid,  121 
Trochanter  (femur),  great,  lesser, 

38 
Tubulization  (nerves),  59 

Ulna,  206,  207 
Upper  limbs,  wounds  of,  197 
Ureter,  182 

Urethra,  wounds  of,  188 
Urine,  infiltration  of,  182  ;  escape 
of,  185,  188 

Van  Lair,  59 

Veins,  wounds  of,  46 ;  big  veins 
(neck),  153 

Velocity,  107;  transit,  5  ;  of  rota- 
tion, 6;  initial,  5,  6;  remaining, 
5,  6;  muzzle,  5,  G;  excessive, 

131 

Velpeau,  159 

Vertebral  column,  wounds  of,  190 

Vessels,  lesions  of,  36 ;  complica- 
tions, 47 

Vis  viva,  7 

Weapons,  i  ;  of  ofifence,  2 
Weir  Mitchell,  55 
Weiss,  Professor,  180 
Wounds,  contour,  161 
Wounds,  tissues,  23 ;    cul-de-sac, 

24  ;  enfilade,  27 ;  lateral,  38,  46 ; 

gaping,    39;    dressing    of,    99; 

periarticular,  103 
Wrist,  wounds  of,  202  ;  diagnosis 

treatment,  203 

Zinc  chloride,  35,  100 
Zinc  gutter  splints,  97 
Zones  of  action  (bullet),  11 


H.    K.    LEWIS,    136;    GOWER   STREET,    LONDON,    W.C,    ENGLAND 


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War  surgery, 


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